dtALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE
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HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE
VOLUME XI
January- December, 1970
EDITOR
William M. Dabney, M.D.
ASSOCIATE EDITORS George H. Martin, M.D. Thomas W. Wesson, M.D.
MANAGING EDITOR Rowland B. Kennedy
EDITORIAL CONSULTANT Betty M. Sadler
EDITORIAL ASSISTANT Nola Gibson
PUBLICATIONS COMMITTEE Lawrence W. Long, M.D. Chairman
Frank L. Butler, Jr.. M.D. William E. Lotterhos, M.D. and the editors
• THE ASSOCIATION Paul B. Brumby, M.D. President
Arthur E. Brown, M.D. President-elect
Raymond S. Martin, M.D. Secretary-T reasurer
William E. Lotterhos, M.D. Speaker
John B. Howell, Jr., M.D. Vice Speaker
Rowland B. Kennedy Executive Secretary
H. Cody Harrell
Assistant Executive Secretary
James F. McPherson, II Executive Assistant
Mississippi State Medical Association 735 Riverside Drive Jackson 39216
HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE
The Journal of the Mississippi State Medical Association is owned and published by the Mississippi State Medical As- sociation, founded December 15, 1856. Editorial, executive, and business offices, 735 Riverside Drive, Jackson, Mississippi. Office of publication, 1201-05 Bluff Street, Fulton, Mis- souri. Copyright 1970, Mississippi State Medical Association.
Volume XI Number 1
January 1970
• EDITOR
William M. Dabney, M.D.
• ASSOCIATE EDITORS George H. Martin, M.D. Thomas W. Wesson, M.D.
• MANAGING EDITOR Rowland B. Kennedy
• EDITORIAL CONSULTANT Betty M. Sadler
• EDITORIAL ASSISTANT Nola Gibson
• PUBLICATIONS COMMITTEE Lawrence W. Long, M.D.
Chairman
Frank L. Butler, Jr., M.D. William E. Lotterhos, M.D. and the editors
• THE ASSOCIATION James L. Royals, M.D.
President
Paul B. Brumby, M.D.
President-elect Walter H. Simmons, M.D.
Secretary-Treasurer William E. Lotterhos, M.D. Speaker
John B. Howell, Jr., M.D.
Vice Speaker Rowland B. Kennedy Executive Secretary H. C. Harrell
Executive Assistant
The Journal of the Mississippi State Medical Association is owned and pub- lished by the Mississippi State Medical Association, founded 1856. Editorial, ex- ecutive, and business offices, 735 Riverside Drive, Jackson, Mississippi 39216; office of publication, 1201-5 Bluff Street, Fulton. Missouri 65251. Subscription rate, $7.50 per annum; $1 per copy, as available. Ad- vertising rates furnished on request. Second-class postage paid at the post office at Fulton, Missouri.
CONTENTS
ORIGINAL PAPERS
Practical Uses of Steroids and Gonadotropins
in Obstetrics 1 Veasy C. B. Buttram, Jr., M.D., Paige K.
Besch, Ph.D., and
L. Russell Malinak,
M. D.
Acute Illness Among
Returnees From Vietnam 8 Robert E. Blount, M.D.
Modern Concepts in Treatment of Respiratory
Insufficiency 13 G. B. Shaw. M.D.
SPECIAL ARTICLE
Radiologic Seminar XCI: Tracheoesophageal Fistula
18 Walter T. Colbert, M.D.
EDITORIALS
Medicaid in Mississippi:
A Bare Bones Beginning 23 Million Dollar Shoestring
The Old Chit-Chat Gets
a Facelifting 25 Newsletter’s New Look
Mandatory Licensure for
Mississippi Nurses 25 Policy Decision
Jackson Chamber Honors
Health Care Team 26 Service Recognition
Our Environment Is at Stake 27 Pollution Dilemma
THIS MONTH
The President Speaking 22 Needed Now
Medical Organization 37 USM Student Health
Service Offers Comprehensive Campus Care Program
Copyright 1970, Mississippi State Medical Association
Convalescing ... but still a long way to go. Anxiety can make it even longer.
Convalescence following medical or surgical procedures may be almost endless to an anxious patient. And, indeed, anxiety with some patients actually retards progress — for example, by inducing insomnia and reducing cooperation.
As physicians have found during nearly 15 years of widespread use, Equanil may be a beneficial part of aftercare. It helps relieve anxiety and tension, thus often aiding your primary therapy.
Indications: For use in management of anxiety and tension occurring alone or as accompanying symptom complex to med- ical and surgical disorders and pro- cedures. Though not a hypnotic, fosters normal sleep through antianxiety and related muscle-relaxant properties. Contraindications: History of sensitivity to meprobamate.
Important Precautions: Carefully super- vise dose and amounts prescribed, espe- cially for patients prone to overdose themselves. Excessive prolonged use has been reported to result in dependence or habituation in susceptible persons, as alcoholics, ex-addicts, and other severe psychoneurotics. After prolonged exces- sive dosage, reduce dosage gradually to avoid possibly severe withdrawal reac- tions. Abrupt discontinuance of excessive doses has sometimes resulted in epilepti- form seizures.
Warn patients of possible reduced alcohol tolerance, with resultant slowing of reac- tion time and impairment of judgment and coordination.
Reduce dose if drowsiness, ataxia or visual disturbance occurs; if persistent, patients should not operate vehicles or dangerous machinery.
Side Effects include drowsiness, usually transient; if persistent and associated with ataxia, usually responds to dose reduc- tion; occasionally concomitant CNS stim- ulants (amphetamine, mephentermine sulfate) are desirable. Allergic or idio- syncratic reactions are rare, but such reactions, sometimes severe, can develop in patients receiving only 1 to 4 doses who have had no previous contact with mepro- bamate. Previous history of allergy may or may not be related to incidence of reactions. Mild reactions are charac- terized by itchy urticarial or erythematous maculopapular rash, generalized or con- fined to groin. Acute nonthrombocyto- penic purpura with cutaneous petechiae, ecchymoses, peripheral edema and fever have been reported. One fatal case of bullous dermatitis following intermittent use of meprobamate with prednisolone has been reported. If allergic reaction occurs, meprobamate should be stopped and not reinstituted. Severe reactions,
observed very rarely, include angioneu- rotic edema, bronchial spasms, fever, fainting spells, hypotensive crises (1 fatal case), anaphylaxis, stomatitis and proc- titis (1 case) and hyperthermia. Treat symptomatically as with epinephrine, anti- histamine and possibly hydrocortisone. Aplastic anemia (1 fatal case), thrombo- cytopenic purpura, agranulocytosis and hemolytic anemia have occurred rarely, almost always in presence of known toxic agents. A few cases of leukopenia, usually transient, have been reported on con- tinuous administration.
Meprobamate may sometimes precipitate grand mal attacks in patients susceptible to both grand and petit mal. Extremely large doses can produce rhythmic fast activity in the cortical pattern. Impairment of accommodation and visual acuity has been reported rarely. After excessive dosage for weeks or months, withdraw gradually (1 or 2 weeks) to avoid recur- rence of pretreatment symptoms (insom- nia, severe anxiety, anorexia). Abrupt discontinuance of excessive doses has sometimes resulted in vomiting, ataxia, tremors, muscle twitching and epilepti- form seizures. Prescribe very cautiously and in small amounts for patients with suicidal tendencies. Suicidal attempts have resulted in coma, shock, vasomotor and respiratory collapse and anuria. Ex- cessive doses have resulted in prompt sleep; reduction of blood pressure, pulse and respiratory rates to basal levels; and occasionally hyperventilation. Treat with immediate gastric lavage and appropriate symptomatic therapy. (CNS stimulants and pressor amines as indicated.) Doses above 2400 mg. /day are not recom- mended.
Composition: Tablets, 200 mg. and 400 mg. meprobamate. Coated Tablets, WYSEALS® EQUANIL (meprobamate) 400 mg. (All tablets also available in REDIPAK® [strip pack], Wyeth.) Contin- uous-Release Capsules, EQUANIL L-A (meprobamate) 400 mg.
EQUANIL
(meprobamate)
Wyeth Laboratories Philadelphia, Pa.
Photo professionally posed.
January 1970
? Doctor:
sissippi Hospital and Medical Service (Blue Cross-Blue Shield) been named fiscal administrator for Medicaid. Commission made iuncement in pre-Christmas news conference, and estimates are t program will cost 6 per cent of $33*4 million budget or about nillion per year to administer.
Selection of fiscal administrator was narrowed when insurance companies pulled out of bidding! The Blue plan was the only bidder for the gargantuan task of program administration, paying physicians, hospitals, nursing homes, and health agencies.
fsident Nixon conducted closed-door conference with AMA leader- p delegation made up of President Dorman and group of Trustees, ee subjects were discussed: Medical manpower shortages , care
its, and services to the poor. AMA has initiated positive pro- ms to get manpower up, costs held, and care delivery to poor.
st recommendations from the McNerney Medicaid Task Force will r heavily upon delivery system and alter federal pay policy, emey wants 5 per cent of Medicare budget or $130 million to toward paying for medical services on a fee-for-time basis for group practice payments. Plan, however, does not exclude -for-service under traditional delivery patterns - yet.
yersity Medical Center growth may be impaired if construction ds are not provided within next year! Facilities are squeez- with record enrollment of 778 students in all programs. Class *73 has 90 beginning medical students, and degree nurse enroll- .t is 142. Various allied programs account for remainder, and student is pursuing combination M.D.-Ph.D. degree.
[A headquarters office has a new telephone number made necessary building expansion. Make a note of 354-4533 with Area Code 66l. Iding addition is virtually complete and scheduled for occupancy next two weeks. Watch for announcement of February open house.
Rowland B. Kennedy Executive Secretary
THE JOURNAL FOR JANUARY 1970
1 0
Surgeons Plan Meet in St. Paul
The American College of Surgeons will hold the second of three 1970 Sectional Meetings in St. Paul, Minn., Feb. 16-18. Some 550 surgeons are expected to attend this intensive three-day program, open to all doctors of medicine. This is the first ACS meeting in St. Paul since 1957. Headquarters hotel is the St. Paul Hilton.
Dr. Frederick M. Owens, Jr., clinical as- sociate professor of surgery, University of Min- nesota Medical School, and his local advisory committee on arrangements, have selected a dis- tinguished faculty to present “How-I-Do-It” clin- ics, panel discussions, scientific papers, symposia, and medical films in general surgery and the spe- cialties of otorhinolaryngology, thoracic surgery and urology.
Subjects to be covered include vascular sur- gery, rhinoplasty and septoplasty, mediastinos- copy, perforation of the esophagus, cardiac in- juries, emergency treatment of head injuries in Viet Nam, arterial surgery for renal disease, pros- tatic carcinoma, Wilms’ tumor, carcinoma of the breast and transportation of the injured patient.
Assisting Chairman Owens are these Minne- sota Fellows of the College: general surgeons Lyle J. Hay; Armond J. Kremen; John F. Perry, Jr.,; Edward W. Humphrey: Lyle A. Tongen; F. Henry Ellis, Jr.; Claude R. Hitchcock. Spe- cialty representatives are Joseph H. Pratt, gyne- cology-obstetrics; Hendrik J. Svien, neurosur- gery; Malcolm A. McCannel, ophthalmology; Jerome A. Hilger, otorhinolaryngology; Donald R. Lannin, orthopedics; John B. Erich, plastic; Loren E. Nelson, proctology; Josiah Fuller, tho- racic, and Edward J. Richardson, urology.
Hotel reservation forms may be obtained by writing directly to the St. Paul Hilton, St. Paul, Minn. 55101, or Mr. T. E. McGinnis, Amer- ican College of Surgeons, 55 East Erie Street, Chicago, 111. 60611. No registration fee is charged Fellows of the College, members of the Candi- date Group, residents or interns who present let- ters of identification signed by chiefs of surgery or the hospital administrator. Non-Fellows pay $15.00. Doctors in the Federal Services pay $7.50.
Dr. Robert J. Kamish, Chicago, assistant di- rector, is in charge of scientific sessions for all Sectional Meetings. Dr. C. Rollins Hanlon, Chi- cago, is director of the College. Dr. Joel W. Baker, Seattle, is president.
HIGHLAND HOSPITAL
Asheville, North Carolina
FOUNDED 1904
A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY
Accredited by the Joint Commission on Accreditation and Certified for Medicare
Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho- therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser- vice work with families, family therapy and an extensive and well organized activities program, including oc- cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may be realized.
High school facilities for a limited number of appropriate patients are now available on grounds. The School Program is fully integrated into the hospital treatment program and is accredited through the Asheville School System.
Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.
Brochures and information on financial arrangements available Contact: Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions
or
Charles W. Neville, Jr., M.D.
Assistant Professor of Psychiatry and Medical Director Area Code 704-254-3201
MISSISSIPPI STATE MEDICAL ASSOCIATION
CHP Study Is Published
The goals, priorities and problem areas of com- prehensive health planning are reviewed in a new document issued by the Health Insurance Council.
Entitled “Community Health Action-Planning — Problems and Potentials,” the 22-page publica- tion is designed as an introductory guide to plan- ning for business and professional leadership in- volved in state and community health activities.
Included is information on the history of health planning, key provisions of planning legislation, suggested organization and relationship of health agencies within a state, criteria for effective area- wide planning agencies, priority actions to be taken by agencies, and barriers that may be en- countered.
In a concluding summary, the author, David Robbins, Controller and Director of Statistics, Health Insurance Association of America, urges a concerted effort by business executives to help
1 i
solve the problems of health facilities, services, manpower and environment.
A special report issued in conjunction with the booklet reviews the progress of the Health Insur- ance Council Program for Community Health Ac- tion-Planning (HiCHAP), noting that “every ini- tial goal of the program has been filled.”
The Council, in its report, said that insurance companies representatives serving as HiCHAP co- ordinators are active in 45 states. Of the Gover- nor’s Advisory Councils now formed in 46 states, the District of Columbia, and Puerto Rico under the Partnership for Health law, insurance compa- ny executives have been appointed to 35 of these councils, and in eight states serve as chairman.
It further reports that insurance representatives are on the boards and committees of over half of the more than 80 areawide health planning agen- cies funded to date by the federal government.
Copies of the health planning document and the HiCHAP progress report may be obtained without charge from the Health Insurance Coun- cil, 750 Third Avenue, New York 10017.
Announcing the Thirty -Third Annual Meeting nf THE MEW ORLEANS GRADUATE MEDIEAL ASSEMRLY
Conference Headquarters — The Roosevelt Hotel- — March 2, 3, 4, 5, 1970
GUEST SPEAKERS
John J. Bonica, M.D.. Seattle, Wash. Anesthesiology
John R. Hill, M.D., Rochester, Minn.
Colon and Rectal Surgery Walter B. Shelley, M.D., Philadelphia, Pa. Dermatology
H. M. Pollard, M.D., Ann Arbor, Mich.
Gastroenterology Walter Lane, M.D., Tampa, Fla.
General Practice
Henry Clay Frick, II, M.D., New York, N.Y. Gynecology
William H. Crosby, Jr., M.D., Boston, Mass. Internal Medicine
Thomas L. Petty, M.D., Denver, Colo. Internal Medicine
David N. Danforth, M.D., Chicago, 111. Obstetrics
Jack A. Dillahunt, M.D., Albuquerque, N.M. Ophthalmology
John J. Niebauer, M.D., San Francisco, Calif. Orthopedic Surgery
William K. Wright, M.D., Houston, Tex. Otolaryngology
Omer E. Hagebusch, M.D., St. Louis. Mo. Pathology
Chester M. Edelmann, Jr., M.D., Bronx, N.Y. Pediatrics
Howard P. Rome, M.D., Rochester, Minn. Psychiatry
Wendell P. Stampfli, M.D.. Denver, Colo. Radiology
Joel W. Baker, M.D., Seattle, Wash.
Surgery
Edwin J. Wylie, M.D., San Francisco, Calif. Surgery
Ralph A. Straffon, M.D., Cleveland, Ohio Urology
Lectures, symposia, clinicopathologic conference, round-table luncheons, medical motion pictures, technical exhibits, and entertainment for visiting wives. (All-inclusive registration fee — S35.00.)
This program is acceptable for twenty-two (22) prescribed hours and nine (9) elective hours by the American Acad- emy of General Practice.
For information concerning the Assembly meeting write Secretary,
The Newr Orleans Graduate Medical Assembly, Room 1538,
1430 Tulane Avenue, New Orleans, Louisiana 70112.
for the debilitated geriatric patient
TABLETS
high potency B-complex and C for nutritional support
AVAILABLE ONLY ON Rx contains water-soluble vitamins only b.i.d. dosage good patient acceptance no odor, and virtually no aftertaste
Each Berocca Tablet contains:
Thiamine mononitrate 15 mg
Riboflavin 15 mg
Pyridoxine HCI 5 mg
Niacinamide 100 mg
Calcium pantothenate 20 mg
Cyanocobalamin 5 meg
Folic acid 0.5 mg
Ascorbic acid 500 mg
Usual dosage is one tablet b.i.d.
Indications: Nutritional supplementation in conditions in which water-soluble vitamins are required prophylactically or therapeutically.
Warning: Not intended for treatment of pernicious anemia or other primary or secondary anemias. Neurologic involve- ment may develop or progress, despite temporary remission of anemia, in patients with pernicious anemia who receive more than 0.1 mg of folic acid per day and who are in- adequately treated with vitamin B12.
Dosage: 1 or 2 tablets daily, as indicated by clinical need. Available: In bottles of 100.
Roche
LABORATORIES
Division ol Hoffmann-La Roche Inc. Nutley. New Jersey 07110
1 Pot Policy Chicago - AMA's new policy position on mari-
hs Hard tine juana minces no words in characterizing can-
nabis as "a dangerous drug. ..and a psycho- ■Lve substance which can have a marked deleterious effect...” Icy says that sale and possession of marijuana should not be ^alized, pointing out that if potency were legally controlled, ice would predictably be an illicit market.
Makers Hit New York - The Tobacco Institute, trade as-
ismoking Spots sociation for cigarette manufacturers, took
full page ads in newspapers to protest what .called "untruthful and misleading statements” by American Can- : Society and American Heart Association in forced-free-time commercials discouraging smoking. TI said that such commercials uuld be stopped. FCC requires networks to give time to offset bes pitches equating smoking with outdoors and the good life.
itists Get Blow Washington - After extensive study, HEW has "m HEW, APHA reported to the Congress that chiropractic
is quackery and that payment for spine punchers* i vices should not be made in Medicare program. American Public s.lth Association followed up by concurring and asking that no ament be made to chiropractors under Title XIX Medicaid. Mis- . sippi program cannot pay cultists under existing law.
sil Dogpatch Gets Dogpatch. Ark. - Sen. J. William Fullbright :leral Handout (D. ,Ark. ) has accomplished what A1 Capp*s
mythical Sen. Jack S. (Good Ole Jack S. ) Phog- ;md has never been able to do in the popular comic strip, "Li'l ler”: He got $120,000 in sure *nuff federal money for Dogpatch,
c. , a private amusement park. Money will provide hillbilly Dis- fland water and sewerage services under public health aegis.
V Disposal Poses Ft. De trick, Md. - The U.S. Chemical and Bio- alth Problems logical Warfare Center has the problem of carry-
ing out President Nixon* s edict to dispose of 3 nation* s stockpile of CBW weapons. Although top secret, deadly senal is known to contain potent strains of anthrax, encephalitis, ague, Q fever, Chikungunya fever, and a host of fatal bugs. CBW LI henceforth be confined to defensive research and vaccines.
THE JOURNAL FOR JANUARY 1970
1 4
equivalent to
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When mixed as directed, each 5 cc. will contain erythromycin estolate equivalent to 125 mg. erythromycin base.
Hr When mixed as f directed, each cc.
will contain erythromycin estolate equivalent to 100 mg. erythromycin base.
mMmmmmmm.
Each tablet contain
Each 5 cc. contain erythromycin estolate equivalent to 125 mg. erythromycin base.
The many forms of Ilosone
Each Pulvule® contains erythromycin estolate equivalent to 125 mg. erythromycin base.
Additional information available upon request.
Eli Lilly and Company Indianapolis, Indiana 46206
Each Pulvule contains erythromycin estolate equivalent to 250 mg. erythromycin base.
900761
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
January 1970, Vol. XI, No. 1
Practical Uses of Steroids and Gonadotropins in Obstetrics
and Gynecology
VEASY C. B. BUTTRAM, JR., M.D., PAIGE K. BESCH, Ph.D., and
L. RUSSELL MALINAK, M.D.
Houston, Texas
The obstetrician and gynecologist frequent- ly encounters a patient who exhibits signs and symptoms which might indicate an endocrine abnormality. Before undertaking a workup, the physician should know just what tests are avail- able to him, what tests might be of benefit both in the diagnosis and treatment, the time and ex- penses involved, and how to interpret the labo- ratory results that he may obtain. The purpose of this paper is to discuss several steroid and gonadotropin determinations that are available to practicing physicians and place emphasis par- ticularly upon their practical use.
Estrogens are phenolic steroids that are se- creted by the ovaries, adrenal glands, testicles and the fetal-placental unit. At the present time, there are known to be at least 20-25 metabolites in the urine which can be considered estrogens. The metabolites that are most important are known as Ei (estrone), E2 (estridiol) and E3 (estriol). Et and E2 are primarily secreted by the
From the Department of Obstetrics and Gynecology, Baylor University College of Medicine.
Read before the Section on Obstetrics and Gynecology, 101st Annual Session, Mississippi State Medical As- sociation, Biloxi. May 13, 1969.
ovaries in the non-pregnant female. A small amount of estrone and estridiol can be secreted by the adrenal gland. Estriol in the non-gravid female is produced primarily in the liver from metabolism of estrone and estridiol; in the gravid female, the major portion of estriol is produced in the fetal-placental unit.
The availability and benefit of tests, the time and expenses involved and the inter- pretation of laboratory results are things a physician must know before undertaking a workup of a patient who appears to have endocrine abnormality. Several steroid and gonadotropin determinations available to practicing physicians are discussed with par- ticular emphasis placed upon their practical use. Diagnostic methods expected to be available in the near future are also con- sidered.
Before an estrogen determination is ordered, it should be emphasized that there are interfer- ing agents which alter the estrogen values ob- tained from urine. These consist of hormones
JANUARY 1970
1
STEROID USAGE / Buttram et al
which inhibit hypothalamic-pituitary-ovarian func- tion, i.e., contraceptives. The cost of a total uri- nary estrogen determination ranges from $15-$30 and the time involved varies from 4-24 hours. Fractionated estrogens on the other hand costs approximately $30-$50, and the time required for such a determination is seven days.
ESTROGEN PEAK
In the pre-menopausal female, estrogen values range from 5-25 /ngm per 24 hours. It is well known that the estrogen value is greatest just prior to ovulation. (See Chart I.) LH release and subsequent ovulation is apparently depen- dent on this peak. There is also a peak of estrogen in the mid-portion of the luteal phase of the cycle. Why females have this second surge of estrogen is not known. It has been theorized that it is due to the release of estrogen from other follicles that were stimulated by FSH in the pre-ovula- tory and post-ovulatory phase of the menstrual
cycle which did not mature to the stage needed for ovulation. These follicles persist during the luteal phase of the menstrual cycle, and it is con- ceivable that they produce estrogen at that time.
The initial peak of estrogen is secreted by the follicle which has been brought to maturity un- der FSH stimulation and subsequently ovulates following LH release. Thus, during the earlier portion of the menstrual cycle, the estrogen value is at its lowest level and may range from 5-10 ^gm for 24 hours (Table I). The level of estro- gen during the mid-portion of the menstrual cycle prior to ovulation and during mid-luteal phase may approach the 25 ^gm peak. The nor- mal value of estrogen in a post-menopausal woman varies from 5-10 ^gm per hour. The major portion of this estrogen comes from the adrenal glands.
The proper clinical use of estrogen determi- nations in the evaluation and treatment of endo- crine abnormalities is variable. In the normal menstruating female an estrogen determination is seldom of benefit in the diagnosis or treatment
-13-11-9-7-5-3-1 1 3 5 7 91113 15
DAY OF CYCLE
Chart I. The variation of the three major urinary estrogens during the menstrual cycle.
2
JOURNAL MSMA
TABLE I
SOME NORMAL URINARY STEROID VALUES IN THE WOMAN
Steroid Pre-Ovulatory Post-Ovulatory Post-Menopausal Pregnancy
Total Estrogen (/i gm) 5-10 5-25 5-10 8-35 mg*
Pregnanediol (mg) <0.2 0.8-3. 5 <0.5 5-30*
17-Ketosteroids (mg) 5-8 5-15 3-8 5-20
17-Hydroxycorticoids (mg) 3-5 3-8 2-5 3-8
Testosterone (/x gm ) 0-10 10-20 10-30 ?
HCG — — — 800-100,000 IU*
* These values vary with gestational age.
of an endocrine abnormality. We feel that a wom- an who is having normal menstrual cycles will have an estrogen level that is within the 5-25 /xgm normal range. Therefore, an estrogen de- termination would be of little practical value to the physician in this patient. In the amenorrheic female, an estrogen determination may be of some benefit (Table II). Further discussion of the practical use of estrogen will follow the intro- duction of the gonadotropins.
GONADOTROPIN VALUES
The pituitary gland is the only organ known to produce human pituitary gonadotropins. The interfering agents which alter the urinary values are estrogens, androgens, and progestins. Some of the frequently used tranquilizers, sedatives, and narcotics also interfere; they suppress the hypothalamus or pituitary gland. The cost ranges from $20-$35, and the time required for this particular determination is approximately two weeks in most laboratories. This is one of the crudest laboratory determinations. Normal values in the pre-menopausal woman range between 6-48 m.u. per 24 hours and in the post-meno- pausal female, between 48-192 m.u. per 24 hours. The clinical usefulness is hampered by the
TABLE II
ESTROGENS MAY BE OF VALUE IN THESE DISORDERS
1. Hypothalamic amenorrhea
2. Amenorrhea-galactorrhea syndrome
3. Hypopituitarism
4. Ovarian agenesis or dysgenesis
5. Premature ovarian failure
6. Congenital absences of the vagina
7. Gonadotropin therapy
8. Estrogen secreting tumors of the ovary
9. Gynecomastia in the male
fact that the determination is so crude. Only values which are extremely high or repeatedly low are of benefit to the practicing physician.
In the normal menstruating female, a total pituitary gonadotropin level is of no benefit in evaluating a problem. If she is menstruating, even if infrequently, she is producing enough FSH to stimulate the follicles to produce estro- gen. The urinary gonadotropic (HPG) value would possibly be low but still within normal range. Only in the completely amenorrheic fe- male is the total pituitary gonadotropin determi- nation of any value to the physician. In the menopausal woman or one with ovarian failure, a tremendous increase in the trophic hormones urinary level occurs. In hypothalamic or pitui- tary pathology, low values for the trophic hor- mones are expected; this is frequently not the case, however. This is possibly due to the wide range of normal for the test and the low value that is reported to be within normal limits.
NORMAL VALUES
In the hypothalamic amenorrheic syndrome, the amenorrhea-galactorrhea syndrome, or in hy- popituitarism, estrogen values are usually in the low normal range. This also is apparently due to the wide range of normal values for urinary estrogen and the fact that the adrenal glands can produce enough estrogen to give a value of 5 pgm or more. Therefore, the culdoscopic find- ing of unstimulated ovaries may be of more practical value than an estrogen or gonadotropin determination. These estrogen deficient patients generally respond poorly to Clomid. An estrogen determination might give some prognostic infor- mation, as we feel that those individuals who have high normal estrogen values respond much more favorably.
JANUARY 1970
3
STEROID USAGE / Buttram et al
Patients with ovarian agenesis or dysgenesis or premature ovarian failure generally have a low normal or low estrogen level and a high gonadotropin titer. Evaluation of the vaginal mu- cosa for estrogen effect is as beneficial as an estrogen determination in the above-mentioned problem and is less expensive.
In those rare cases of congenital absence of the vagina, where a vaginal smear cannot be ob- tained, an estrogen determination may be of some benefit to the physician. A high normal estrogen level would indicate that ovaries are present. A urinary cytogram for estrogen effect may also be of value.
GONADOTROPIN THERAPY
In the recent past, gonadotropin therapy has been used with qualified success in infertile pa- tients with low gonadotropic hormone release. At the present time, it is difficult to know just how much FSH to administer and the amount required varies considerably in each individual. Estrogen values during and following gonadotro- pin therapy have been of some benefit. During gonadotropin therapy, the estrogen value should rise. Evaluation of this estrogen output is bene- ficial in evaluating further FSH need. However, because estrogen determinations are time consum- ing and costly; their use in patients receiving gonadotropin therapy has been less than ideal.
Occasionally, an estrogen secreting ovarian tumor may be diagnosed by estrogen determina- tions. Generally, this is not the case. Most pa-
tients with ovarian tumors that secrete estrogen will have a palpable adnexal mass. Following ex- cision of a functioning ovarian tumor, subsequent estrogen determinations might indicate recurrence or metastatic disease. Likewise, in male patients with gynecomastia, an estrogen determination may be of some benefit in both diagnosis and treatment.
PRACTICAL USES
The greatest practical use of estrogen determina- tions is in the pregnant female. Placental insuffi- ciency may be associated with postmaturity, dysma- turity, diabetes, and toxemia of pregnancy. The estrogen values in pregnancy are increased 1,000 fold over those in the non-pregnant female. Re- cent investigations indicate that urinary estrogen levels in the third trimester of pregnancy are in- dicative of feto-placental well being. It is impor- tant that frequent determinations be obtained; delivery of the infant should be considered when an estrogen value drops 50 per cent or more. The total estrogen value is not as important as is a decrease which is noted on serial determina- tions. In some cases, fetal death in utero may be diagnosed by a low estrogen level. Also, it has been recommended by some authors that estro- gen values accurately reflect fetal size and should be performed on any patient prior to elective repeat cesarean section.
Progesterone is known to be produced in the ovary, adrenal, testes, and placenta. There are more than 20 compounds in the urine which can be considered progesterone metabolites; of these, pregnanediol (PL>) is the most important. (See
Chart 11. Urinary pregnanediol excretion throughout the normal cycle.
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Chart II.) Any agent which contains estrogen, progesterone or androgen can suppress the hy- pothalamus and the pituitary gland and thus in- terfere with the pregnanediol determination. The cost of this test is approximately $15 and the time required is two days (Table II). The non- gravid female excretes 0. 5-0.9 mg pregnanediol each 24 hours in the follicular phase of the men- strual cycle and 0.9-3. 5 mg each 24 hours in the luteal phase. In the pregnant female, the preg- nanediol values increase approximately 2.75 mg/24 hours each gestational month. The normal day-to-day variation in excretion is considerable; thus the test is of little value.
There is no practical value of pregnanediol determinations in pregnancy. It has been felt that the P2 value was indicative of fetal-placental well being. Recent investigations have virtually disproved this hypothesis. In the menstruating female, the pregnanediol value may be of some benefit for detection of ovulation, but other tests such as basal body temperatures or endo- metrial biopsies are as enlightening and less ex- pensive. In the amenorrheic female, P> values are never of benefit, simply because the amenor- rheic patient rarely ovulates.
STEROID METABOLISM
Urinary 1 7-hydroxycorticoids are produced only from the metabolism of steroids produced in the adrenal glands. There are many compounds in the urine which react chemically as 1 7-hy- droxycorticoids. The interfering agents are iodides, paraldehyde, chloral hydrate, sulphur drugs, chlorophenothiazine, spironolactones, Furadantin, quinine, colchicine, Darvon, bilirubin, glucose, coffee, spinach, and others. Stress may cause an increase in 1 7-hydroxycorticoids. When the pa- tient enters the hospital for endocrine evaluation, she is generally anxious; thus a temporary in- crease in 1 7-hydroxycorticoids may occur. The cost of this procedure is approximately $15, and the time involved is usually three days. The nor- mal values vary with each laboratory. Generally, 5-10 mg. per 24 hours is considered normal for a male and 2-8 mg. per 24 hours for a female.
The clinical use of 1 7-hydroxycorticoids is re- lated to its value as a screening procedure for adrenal disorders. In Cushing syndrome in which an over-production of cortisol occurs 1 7-hydroxy- corticoids are increased. In congenital and ac- quired adrenal hyperplasia, the 1 7-hydroxy- corticoids are normal or low normal. These pa- tients have compensated for their enzymatic de-
fect and thereby produce enough hydrocortisone to survive. In Addison’s disease and panhypo- pituitarism, low normal or slightly subnormal levels are found. These values are only sugges- tive, not diagnostic. Also, Addison’s disease and panhypopituitarism cannot be differentiated by a 1 7-hydroxycorticoid value alone.
ORIGIN OF 17-KETOSTEROIDS
Origins of 17-ketosteroids are the ovaries, adrenal glands, testicles and placenta. There are a number of 17-ketosteroids in the urine but only seven are of importance. Among the interfering agents are such substances as ascorbic acid, Dori- den, morphine, mephrobamate. Stress may also give false high values. The cost ranges from $7.50-$ 15 and the time required is around two days. Most procedures used to detect urinary 17-ketosteroids are very crude, and at best the determination is a measurement of weak androgens produced in the body. Twenty to 40 per cent of the 17- ketosteroid values may be non-specific urinary chromogens. For example, of 12 mg/24 hours for a female, 2-4 mg. of this determination may be interfering urinary chromogens that are not 1 7-ketosteroids. The normal values vary with the laboratory; the male range is 8-20 mg. per 24 hours, and that of the female is 5-15 mg. per 24 hours.
As with the 1 7-hydroxycorticoids, 17-ketoster- oids are used primarily as a screening procedure for adrenal pathology. When an increase in 17- ketosteroids is obtained, it should be assumed that the problem lies in the adrenal gland until proven otherwise. Secretion of 17-ketosteroid in- creases in adrenal tumors, Cushing syndrome, congenital adrenal hyperplasia and possibly in acquired adrenal hyperplasia and borderline adrenal dysfunction. In Addison’s disease and panhypopituitarism low normal to sub-normal values of 17-ketosteroids are present. Although ovarian pathology may cause an increase in 17- ketosteroids, this is generally not the case. Ele- vated 17-ketosteroid values are occasionally as- sociated with adrenal rest tumors of the ovaries or arrhenoblastomas. A discussion of 17-keto- steroid values in patients with enzymatic pathol- ogy of the ovaries and/or the adrenal glands will appear later in this paper.
Testosterone can be produced in the ovaries, testicles and probably to a small degree by the adrenals. Precursors of testosterone are produced abundantly by each of these glands. Conver- sion of these precursors to testosterone may
JANUARY 1970
5
STEROID USAGE / Buttram et al
take place in the liver and other peripheral sites. The interfering agents are corticoids, estro- gens, progestins, and androgens, as these may al- ter the biosynthesis of the secreting endocrine gland. The cost varies from $35-$55, and the time required is approximately two weeks. Testoster- one is not a 1 7-ketosteroid. It is present both in the urine and the plasma. Androstenedione is a 1 7-ketosteroid which is found only in the plas- ma. Dehydroepiandrosterone (DHEA) is the most androgenic 1 7-ketosteroid found in the urine. If testosterone is given an androgenicity value, androstenefione is one-tenth and DHEA is one-thirtieth of that value. The metabolism of these compounds are shown in Chart III. Urinary 1 7-ketosteroids are measurements of the weakest androgens produced in the body and do not re- flect unmetabolized androstenedione or testoster- one. The normal values for urinary testosterone in the male are 30-200 ^gm for 24 hours and 0-20 gm for 24 hours in the female. In the plasma, the value is approximately 0.68 g gm and 0.10 /xgm respectively. In the normally menstruating fe- male, testosterone levels vary throughout the menstrual cycle; the peak of testosterone is around the time of ovulation, apparently stimu- lated by the LH peak.
Metabolism of Some Endogenously Produced Androgens
D ehyd ro epiandro s te ro ne
1 7-ketosteroids. Occasionally, both testosterone and the 1 7-ketosteroids are increased. Using these generalizations, a differentiation between primary ovarian and primary adrenal enzymatic pathol- ogy can usually be made. When an enzymatic deficiency in either gland is so mild that it cannot be detected by measurement of testosterone or 1 7-ketosteroids, a diagnostic dilemma is present. A similar diagnostic problem arises when enzy- matic deficiencies are present in both endocrine glands.
URINARY TESTOSTERONE
Androgen secreting ovarian tumors, such as arrhenoblastoma and hilus cell tumors, are gen- erally associated with an increase in urinary tes- tosterone. These particular tumors may cause no increase in 1 7-ketosteroids. In contradistinction, adrenal tumors usually secrete a large amount of 1 7-ketosteroids and little testosterone. Plasma testosterone values have not as yet been well cor- related with disease processes.
Human chorionic gonadotropin is produced by the placenta. There are multiple methods of de- tection of this trophic hormone. The hemaggluti- nation tests have a sensitivity as low as 800-1000 IU of HCG. The time required is generally 2-4 hours and the approximate cost is $5. The latex agglutination tests have a sensitivity as low as 2000 IU of HCG and the time required is 2-3 minutes; the cost is around $3. The complement fixation test is rarely used today. The radioim- munoassay technique, which is relatively new, is very specific and sensitive, and can detect HCG values as low as 0.06 HCG per ml. of serum. The bioassay techniques used in the past were fairly specific and quantitative for HCG but due to the crudeness and the methodology involved, these techniques are currently seldom used.
LH AND HCG DETERMINATIONS
Chart 111. Metabolism of some endogenously pro- duced androgens.
Testosterone determinations are useful in dif- ferentiating ovarian from adrenal pathology. When a major enzymatic deficiency exists in the ovary, excess androgen production occurs gener- ally in the form of elevated testosterone. Occa- sionally, both testosterone and 1 7-ketosteroids are elevated. When a major enzymatic deficiency exists in the adrenal gland, excess androgen pro- duction occurs generally in the form of elevated
Lutenizing hormone (LH) and human chori- onic gonadotropin (HCG) crossreact immuno- logically. Thus, 10 units of LH plus 10 units of HCG react immunologically as 20 units. In the normally menstruating female, the peak of LH is around mid-cycle and ranges from 200-300 IU HCG (Chart IV). In the post-menopausal female, the LH value may be 600 IU HCG. If a sensitive immunological test for HCG is used, a positive pregnancy test in a post-menopausal female may occur when the LH titer approxi- mates 600-800 IU HCG. HCG titers are de- tectable on the 24th day of pregnancy; by day
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MEAN URINARY EXCRETION OF FSH & LH ACTIVITY ARRANGED ACCORDING TO THE DEVIATIONS FROM THE TIME OF MAXIMAL LH EXCRETION IN EACH CYCLE (64 NORMAL CYCLES)
DAYS
Composition pattern of FSH and LH excretion. Vertical lines represent the standard error. (From Stevens, 1966.)
Chart IV. Pattern of LH & FSH during the normal cycle.
30, there is a 100-fold increase, and by day 42, the value is increased some 3000 fold. The peak of HCG is noted around the 50th-70th day of gestation.
The best clinical use of HCG determinations is in diagnosis of pregnancy. If a sensitive tech- nique is used properly, a positive pregnancy test occurs by day 30 of the menstrual cycle or 16 days after conception. Most physicians delay this determination until day 42 because some women ovulate later than day 14.
This test is useful in the diagnosis of hydatidi- form mole and choriocarcinoma; it must be stressed, however, that very high levels of HCG may occur in normal pregnancy during the third month. The post-treatment care of the patient with trophoblastic disease is enhanced by very sensitive techniques for HCG determinations.
In the near future, the obstetrician and gyne-
cologist will have several new methods for ster- oid and gonadotropin determination which will aid both in diagnosis and treatment of endocrine abnormalities. The competitive protein binding technique for estrogen, progesterone and testos- terone appears to be a very rapid, accurate and sensitive method for detection of these steroids, although it is still in the early stages of develop- ment. The radioimmunoassay for FSH and LH and other trophic hormones is also in its infancy. This technique is complex but holds a lot of promise for all physicians and individuals inter- ested in the field of reproductive physiology'. Production and secretion rates are complicated and have not to date been useful in clinical ob- stetrics and gynecology. Conversion studies of steroids are also complex, but they appear prom- ising for future practicing physicians. ***
5353 Dora Street (77005)
JANUARY 1970
7
Acute Illness Among Returnees
From Vietnam
ROBERT E. BLOUNT, M.D.
Jackson, Mississippi
It is estimated that, during 1970 more than 6,000 Mississippians will be returning to the United States after completing a 12-month tour of duty in Vietnam. Traveling by jet, these troops may arrive home during the incubation period of a number of tropical diseases.
Those who have engaged in combat in the Central Highlands of South Vietnam probably have been exposed to virulent strains of Plasmodium falciparum malaria. These troops have been tak- ing a tablet containing 300 mg. Chloroquine (base) and 45 mg. primaquine (base) once weekly as chemoprophylaxis. Some are receiving a daily dosage of 25 mg. of diaminodiphenyl- sulfone (Dapsone) as a third chemosuppres- sive agent. On being rotated from Vietnam, each individual is issued a supply of the chloroquine- primaquine tablets with instructions to take one each week for eight weeks. He is warned not to use these combined tablets for the therapy of any clinical illness because of the hemolytic po- tential of the larger dosage of primaquine in- volved. Most returning troops are also given a supply of Dapsone tablets and instructed to take one daily (in addition to the weekly doses of chloroquine-primaquine) for 28 days after leav- ing the high-risk area.
Because certain strains of P. falciparum, found in Southeast Asia (and in South America), are resistant to chloroquine, as well as to almost
From the Departments of Preventive Medicine and Medicine, University of Mississippi School of Medi- cine.
Read before the Section on Preventive Medicine, 101st Annual Session. Biloxi, May 14, 1969.
all of the synthetic antimalarials including Quinacrine, Proguanide, Pyrimethamine, Amo- diaquine, and Primaquine, some of these re- turnees will experience clinical disease due to P. falciparum. These infections may show little
Troops returning by jet to the United States from service in Vietnam may easily arrive home during the incubation period of a number of tropical diseases. The author discusses the symptoms and treatment of malaria, melioidosis , leptospirosis, tsutsuga- mushi disease, Japanese B encephalitis and other communicable diseases found in Viet- nam.
clinical improvement or drop in parasitemia lev- els after 1.5 gm. (base) of chloroquine in three days. Parenteral administration of chloroquine also proves ineffective. Recrudescence rates range from 50 per cent to 80 per cent after chloroquine therapy.
Fatalities due to P. falciparum malaria have been increasing in the USA during the past few years. Dangerous levels of parasitemia occur with incredible rapidity, leading to complications such as cerebral malaria, acute renal insufficiency, massive intravascular hemolysis, disseminated intravascular coagulation, or acute pulmonary edema with pleural effusion.
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A high index of suspicion for malaria must be maintained when troops from Southeast Asia be- come ill. This also holds true for tourists, seamen. Peace Corps volunteers and airline crews. Re- peated thick as well as thin blood smears should be obtained and studied, in order to rule out ma- laria, in any illness developing among such per- sonnel. An accurate species diagnosis is neces- sary since the drug of choice for Vivax or Quar- tan malaria is still Chloroquine, 1.5 gm. of the base (or 2.5 gm. of the salt) in 3 days. Then Primaquine 15 mg. daily for 14 days, being ef- fective against the exoerythrocytic or tissue stages or all malaria species, usually accom- plishes a radical cure of vivax and quartan ma- laria.
For chloroquine resistant strains of P. falci- parum malaria, combined drug therapy utilizing at least two antimalarials is required, at least un- til more ideal therapy is available. Currently quinine is once again the drug of choice for any individual who subsequently develops P. falci- parum malaria contracted in Southeast Asia. Quinine, 650 mg. every eight hours, for 10 days (total 20 gm.) is given concurrently with pyri- methamine 25 mg. twice daily for the first three days (total 150 mg. in 3 days). Beginning on day seven diaminodiphenylsulfone, (currently available only in military hospitals) 25 mg. daily, is begun and continued for the next four weeks (28 days).
FALCIPARUM MALARIA
In patients seriously ill with falciparum ma- laria, marked electrolyte and hemodynamic changes occur. Careful monitoring of fluid intake and output and daily recording of body weight is indicated. In the critically ill, measurement of central venous pressure is helpful in the avoidance of fluid overloading.
If oliguria develops the use of the osmotic di- uretic mannitol, following adequate hydration, appears helpful in restoring sufficient urine out- put to prevent oliguric renal failure. However, if a test dose of 20 gm. (as a 20 per cent solu- tion) of mannitol does not produce a urine vol- ume of at least 60 ml/hr for each of the next two hours, fluids should be restricted and the patient treated as for acute renal failure.
Dennis et al. have demonstrated a rapid con- sumption of coagulation factors plus evidence of a defibrination syndrome in patients critically ill with P. falciparum malaria. In view of this evi-
dence that disseminated intravascular coagula- tion occurs in such patients, the cautious admin- istration of heparin (0.5 mg/kg intravenously every eight hours) would appear to be indicated. Both animal and clinical experience support this.
In cerebral malaria, or when the acutely ill falciparum malaria patient is unable to take or retain quinine orally, the initial dosage of quinine should be given intravenously. Rapid intravenous administration of quinine may prove disastrous. If given slowly, preferably by infusion, in dosage not exceeding 640 mg. every eight hours, the drug is well tolerated, provided urine output is adequate. If severe oliguria or anuria is present, dangerous quinine blood levels may result. Oral administration is to be resumed at the earliest practicable moment.
MASSIVE HEMOLYSIS
Massive hemolysis with marked hemoglobi- nuria has occurred in nonimmune American soldiers during the primary attack of P. falciparum malaria, with or without quinine therapy. The use of adrenal steroid therapy, such as dexa- methasone, has appeared to be useful. Carefully matched transfusions, preferably of packed eryth- rocytes, may be useful in correcting anemia that is of life threatening severity. If the blood smear shows parasitemia, quinine should be cau- tiously administered. In many of the “blackwater fever” cases in or from South Vietnam, para- sitemia has been demonstrated.
Dexamethasone has been effective in the man- agement of the cerebral edema occurring in cere- bral malaria. Rapid reversal of choked discs and clearing of the sensorium has been noted. In the management of a person having just returned from South Vietnam, who is acutely ill with falciparum malaria, a careful search also is indicated for com- plicating or coexisting acute infectious diseases.
AVAILABILITY OF QUININE
A brief telephone survey of hospital pharma- cies in Mississippi failed to locate quinine di- hydrochloride for intravenous use, except for the Veterans Administration Hospital in Jackson. Qui- nine sulfate for oral use was available in only a few. It is suggested that preparations of quinine for both oral and intravenous use be stocked in every pharmacy for emergency therapy of chloro-
JANUARY 1970
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VIETNAM RETURNEES / Blount
quine resistant strains of falciparum malaria. It is further suggested that valuable time not be lost by the trial of chloroquine therapy for P. fal- ciparum malaria imported from Southeast Asia.
Anopheline vectors are present in some parts of every one of the continental United States. Thus there is the possibility of these indigenous vectors becoming infected with not only P. vivax gametocytes, but with gametocytes of chloro- quine resistant strains of P. falciparum malaria. This could lead to outbreaks of malaria due to mosquito transmission of these introduced strains of malaria.
Fortunately, it has been proven that one dose of 45 mg. of primaquine base will render adult gametocytes non-infective for mosquite vectors for a period of at least 12 days. If each individ- ual, returning from Southeast Asia, will take one chloroquine primaquine tablet each week for eight weeks, as instructed, the sporontocidal effects of primaquine should effectively prevent infection of indigenous anophelines. This at least reduces the threat of malaria once again becom- ing endemic in the United States.
MELIOIDOSIS
Another disease that should be suspected in any febrile returnee from Southeast Asia is mel- ioidosis. This disease, endemic in Southeast Asia, is caused by the motile, bipolar, poorly staining gram negative bacillus Pseudomonas pseudomal- lei. Some 100 cases were recognized in the French forces in Indochina between 1948 and 1954. Ap- proximately 140 cases have occurred in American Armed Forces personnel. There is serological evidence of many inapparent infections especial- ly among the South Vietnamese. The clinical manifestations are protean, ranging from a ful- minant septicemia, with multiple visceral and cutaneous abscesses as well as pneumonia, to a relatively mild pulmonary infiltrate that may mimic tuberculosis. Acute suppurative arthritis, cutaneous ulcers, osteomyelitis, or draining si- nuses of skin, muscle and bone may appear. Sev- eral recent burn evacuees to the Brooke Army Burn Center, all without evidence of pulmonary lesions, have developed septicemia due to Ps. pseudomallei.
The organism is often easily recovered, using ordinary culture media from sputum, cutaneous and other abscesses, or ulcers, or from the blood
stream. Whitish mucoid colonies develop char- acteristic wrinkling within 4 or 5 days. The cul- ture medium of choice appears to be eosin meth- ylene blue (EMB), and the initial culture has in- variably required a minimum of 48 hours incu- bation. Serologically, culture proven cases usual- ly develop hemagglutination titers of 1:40 and above, and complement fixation titers of 1:8 or above.
FULMINANT INFECTIONS
Most of the fulminant infections with high spiking fever, septicemia and multiple visceral abscesses have occurred in troops in South Viet- nam. So far in the United States, except for the burn cases, the few returnees from South Vietnam who have developed clinically proven melioidosis usually have shown an onset with fever, and cough, productive of scanty purulent blood streaked sputum, together with pleuritic pain. Chest films in those with pulmonary changes have shown infiltrates varying from diffuse ir- regular nodular densities to an almost lobar pneumonic consolidation. Cavitary lesions are not infrequent. Most of these cases have shown rapid improvement on full doses of multiple antibiotic therapy. Based on sensitivity studies and clinical observations, effective antibotics in therapy of mel- ioidosis are tetracycline, chloramphenicol, kana- mycin. novobiocin, and sulfisoxazole. Almost uniform resistance has been observed against penicillin, ampicillin, cephalothin, colistimethate and streptomycin.
In the critically ill patient, massive doses of a combination of antibiotics such as chlorampheni- col, tetracycline and sulfisoxazole, have led to recovery in few cases, but these fulminant infec- tions have shown a high mortality rate. In most of the returnees to the United States, the illness has shown a subacute pulmonary lesion, respond- ing well to combinations of antibiotic therapy. Bennett of the Communicable Disease Center has reported that chloramphenicol and kanamycin in combination are antagonistic, at least in vitro.
LEPTOSPIROSIS
Clinical cases of leptospirosis varying in se- verity from mild episodes of an “aseptic menin- gitis”-like syndrome to an icteric state with se- vere liver and kidney involvement may occur in men who have served in the Mekong Delta. A large proportion of infections are inapparent.
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The signs and symptoms of leptospirosis are generally non-specific. After an incubation pe- riod usually of 10-12 days, but ranging from 3 to 30 days, the onset may be insidious or abrupt. A rising fever accompanied by chills, myalgia, headache, and malaise is common. An early leptospiremia persists for approximately 6 to 8 days, occasionally for two weeks. During the first week the organisms may sometimes be found in the cerebrospinal fluid. Fever of 102 to 104 degrees F may persist for several days to a week. During the leptospiremic period conjuncti- val suffusion, retro-orbital pain, pharyngitis, mus- cle tenderness, nausea, vomiting, abdominal pain, relative bradycardia, adenopathy and nuchal rigidity are frequently noted. Signs of meningeal irritation usually appear early and often be- come pronounced during the second week. There is increased spinal fluid pressure and a delayed appearance of lymphocytic pleocytosis. In milder cases of leptospirosis, meningeal signs frequently dominated the clinical picture. Such cases prob- ably might have been termed “aseptic meningitis” a few years earlier.
CLINICAL IMPROVEMENT
With the disappearance of leptospiremia, clin- ical improvement occurs, although a secondary febrile episode may appear. By the 6th to 10th day detectable antibodies are present. Full re- covery usually occurs within two weeks in mild cases. Leptospiras appear in the urine after the first week of illness. Shedding of leptospiras in the urine is more pronounced the first weeks after clinical improvement is noted, but may occur in- termittently for three or more months thereafter. In milder cases, a slight leukopenia occurs. Where there is liver involvement, the white cell count may be elevated (above 15,000 cells per cu. mm.) with neutrophilia. Renal findings vary from a mild transient proteinuria, usually noted in benign leptospirosis, to a severe nephritis with hematuria, casts, and oliguria, or even anuria.
Severe nephritis frequently is noted in the ic- teric form of leptospirosis. Jaundice in these cases usually develops in the middle or latter part of the first week. The liver becomes enlarged and tender. Mucous membrane and cutaneous ecchy- moses are frequent, and gastrointestinal hemor- rhage can occur. The mortality in jaundiced pa- tients who are severely ill ranges from 50 to 30 per cent. Fatal anicteric cases are extremely rare.
Paired or serial sera specimens may reveal a 4 fold (diagnostic) rise in agglutination or com-
plement fixation titer. Leptospira may be isolated by culture or animal incubation of blood or cere- brospinal fluid in the first week of illness, or from urine after the first week. Fluorescent antibody technics are very promising.
No really effective specific therapy is available. Penicillin is apparently useful only when admin- istered in the first 48 hours of illness.
TSUTSUGAMUSHI DISEASE
Tsutsugamushi Disease (scrub typhus), a mite- borne rickettsial disease, was seen in great num- bers by medical officers in the South and South- west Pacific in WWII. Cases currently appear among troops who have been operating in cer- tain grasslands areas of South Vietnam. A small eschar 0.5 to 1.0 cm. in diameter usually indi- cates the site where the infected mite took a blood meal. On or about the 5th day of this febrile ill- ness a faint erythematous macular rash may ap- pear for a few hours. The leukocyte count is usually not remarkable. Paired sera should be obtained and a four-fold rise in the OXK (Weil- Felix) titer is considered diagnostic. A rise in OXK titer may also occur in leptospirosis and in mite-borne relapsing fever. Tetracycline usually produces a prompt defervescence. Tetracycline therapy does not prevent a subsequent diagnostic rise in serologic titer. The mortality rate from clinical illness due to the South Vietnam strain of Rickettsia tsutsugamushi (orientalis) is quite low compared to that of strains found in the Southwest Pacific.
JAPANESE B ENCEPHALITIS
A very few cases of Japanese B encephalitis have occurred among American troops in South Vietnam. This mosquito-borne virus disease may present as a severe diffuse encephalomyelitis. Many inapparent infections may occur simul- taneously. Paired sera should be obtained for serologic diagnosis.
Complement fixing or neutralizing antibodies develop. The virus can be often recovered from the brain of fatal cases. Therapy is symptomatic and supportive.
Some intestinal helminthiasis may be expected among Vietnam returnees. Hookworm infestation may be responsible for considerable epigastric distress. With the stools showing occult blood, the diagnosis of peptic ulcer has been suspected. In a number of cases, a peripheral blood eosino-
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JANUARY 1970
VIETNAM RETURNEES / Blount
philia has directed attention to the possibility of intestinal parasitism. Ascariasis, strongyloidiasis and trichuriasis may also appear among returnees.
TROPICAL SPRUE
A few cases of tropical sprue have been recog- nized among American service men returning from Vietnam. Should such a returnee show a per- sistent diarrhea, and no demonstrable pathogens, a d-zylose absorption test is indicated. A Sudan IV stain of a fecal smear may show neutral fat globules, or fatty acid crystals. A biopsy speci- men of jejunal mucosa may show villous atrophy, or flattening. Cases of tropica! sprue usually fail to respond to a gluten free diet. Most of the cases from South Vietnam have responded to 15 mg. daily dosage of folic acid given over a 12-week period. The acutely ill patient with severe diar- rhea and weight loss should also be given tetra- cycline 1 gm. daily for 30 days followed by 0.5 gm. daily for another 5 months plus folic acid. 15 mg. daily and vitamin Bi2 30 micrograms intra- muscularly each week for six months.
HIGH PLAGUE INCIDENCE
With an enormous plague infected rodent res- ervoir in South Vietnam, a high incidence of plague among the Vietnamese is not unexpected. American troops have received an effective plague vaccine and so far have developed only three clinical cases of the disease. Two of these presented with fever and inguinal adenopathy; all three cases survived. Plague should be sus- pected in any returnee who develops a febrile illness and a regional adenopathy within 10 days of his departure from Vietnam. Needle aspira- tion of the bubo may permit recovery and identi- fication of the Pasteurella pestis by smear, cul- ture, and/or animal inoculation. Immunofluores- cent staining provides a highly specific, quick and reliable means of diagnosis. Although strains of P. pestis in South Vietnam have shown some in- crease in resistance to streptomycin in vitro, this
antibiotic is still the drug of choice. Large doses (0.5 gm. IM of 3 h for 2 days followed by 2 gm. daily for 10 days) are recommended.
TUBERCULOSIS
There is a high incidence of tuberculosis among the Vietnamese. Many American troops have been tuberculin tested. Those with records of negative intradermal tuberculin (purified pro- tein derivative) should be retested annually for several years. Those with positive intradermal tests should have annual chest x-rays. Recent converters should be treated.
Schistosomiasis has not yet proven to be en- demic in South Vietnam. Infectious hepatitis in a relatively mild form has occurred in American troops. Leprosy does occur among the Vietnam- ese, but the incidence of leprosy among Ameri- can returnees is expected to be infinitesimally low.
Other infectious diseases endemic in South Vietnam are essentially cosmopolitan in occur- rence and have not been discussed. ***
2500 North State St. (39216)
REFERENCES
1. Hunter, G. S., Ill; Frye, W. W.; and Swartzwelder,
J. (editors): A Manual of Tropical Medicine, ed. 4, Philadelphia, W. B. Saunders Company, 1966.
2. Blount, R. E. : Chloroquine Resistant Falciparum Malaria (editorial), JAMA 200:886 (June) 1967.
3. Blount, R. E.; Alstatt, L. B.; Conrad, M. E.; Blount, R. E., Jr.; Drew, R.; and Tigertt, W. D.: Panel on Malaria, Ann. Int. Med. 70:127-153 (Jan. 1) 1969.
4. Weber, D. R.; Douglass. L. E.; Brundage, W. G.; and Stallcamp, T. C.: Acute Varieties of Melioidosis Oc- curring in U. S. Soldiers in Vietnam, Am. J. Med. 46:235-244 (Feb.) 1969.
5. Alexander, A. D.; Gochenour, W. S., Jr.; Reinhard,
K. R.; Ward, M. K.; Yager, R. H.: Am. Public Health Assn. Diagnostic Procedures and Reagents, Chapter on Leptospirosis, ed. 5, 1969.
6. Gilbert, D. N.; Moore, W. L.; Hedberg, D. L.; and Sanford, J. P.: Potential Medical Problems in Per- sonnel Returning from Vietnam, Ann. Int. Med. 68:662-678 (March) 1968.
7. Greenberg, J. H.: Public Health and the Vietnam Returnee, JAMA 207:697.
8. Dennis, L. H., et al: A Coagulation Defect and Its Treatment with Heparin, in Malaria, Military Medi- cine 131:1107-1110 (Supplement).
A complete bibliography will be furnished on request to the author.
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Modern Concepts in Treatment Of Respiratory Insufficiency
G. B. SHAW, M.D. Jackson, Mississippi
In the past several years there has been a great emphasis on the treatment of respiratory insufficiency. This has come about for several reasons. First, there is an increasing incidence of obstructive lung disease in the population in general. Second, there is increased information coming from the research lab, leading to improved knowledge in the complex problems involved in respiratory insufficiency. Third, better instruments are available giving quicker results on various parameters used to follow the patient with this condition. Finally, there is increasing sophistica- tion in the instruments and machines used in managing these patients. All of these factors have culminated in improved methods in caring for the patient with respiratory insufficiency.
Respiratory failure is not a disease per se, but a syndrome of ineffective lung function due to many causes. The literature defines respiratory failure in terms of a P02 less than 50 mm. Hg. and/or PCOL» greater than 50 mm. Hg. This suf- fers the same drawback as trying to define uremia as a BUN above a certain number or congestive heart failure as an end-diastolic pressure of great- er than a certain figure. Nevertheless, we need specific values in order to quantitatively appraise the problem.
For the most part respiratory failure is thought of as the end result of obstructive lung disease. However, there are numerous causes of respira- tory failure which may be a result of dysfunction
Read before the Section on Medicine, 101st Annual Ses- sion, Mississippi State Medical Association. Biloxi, May 14. 1969.
of any of the organs responsible for respiratory effort.
In the brain, the respiratory center is respon- sible for initiating the inspiratory effort. Though many things are known to act on this center.
Many changes in the handling of patients with respiratory insufficiency have developed in the last several years as a result of im- proved understanding of the pathophysiol- ogy of the problem. The causes of respira- tory failure are reviewed and management discussed.
there remains a large gap in the knowledge of this complex system. Among the conditions known to affect the respiratory effort are pri- mary alveolar hypoventilation, and its related condition, the Pickwickian syndrome. Overdosage of certain drugs including sedatives, tranquil- izers and narcotics are known to depress respira- tion. Additionally, certain other conditions such as brain trauma and cerebrovascular accidents may well be a cause for respiratory insufficiency. The spinal cord may be involved with a number of conditions such as poliomyelitis, Guillain-Barre syndrome, trauma and spinal anesthetics. Periph- eral neuritis and myasthenia gravis may cause respiratory failure.
Distortion of the thoracic cage with kyphoscoli-
JANUARY 1970
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Respiratory Insufficiency / Shaw
osis, various kinds of trauma and especially the flail chest may lead to under-ventilation. Changes occurring in the pulmonary circulation, which may include pulmonary embolus, and acute left ventricular failure, caused by myocardial infarc- tion, may precipitate respiratory failure. Finally, the many types of lung disease including pneumo- thorax, pleural effusion, progressive pulmonary fibrosis and obstructive lung disease may all even- tuate in respiratory failure. So it is obvious that any condition of proper severity involving any of the organs effecting the respiratory system may produce a state of respiratory insufficiency.
Oxygenation of the body is one of the two main functions of the lung. Several terms which are used in describing the state of oxygenation include oxygen content, oxygen saturation, and oxygen partial pressure. The oxygen content is the actual volume of oxygen per 100 cc. of blood. In normal arterial blood this is 19.5 cc. per cent, assuming a normal hemoglobin of 15 gm. Any reduction of hemoglobin would reduce the oxygen content of blood. Normal oxygen saturation is 95 per cent, indicating 95 per cent of the hemoglobin in the arterial system is saturated with oxygen.
OXYGEN PRESSURE
The partial pressure of oxygen relates to the amount of dissolved oxygen in the plasma and is directly related to the oxygen saturation. It is the partial pressure of the oxygen which is im- portant, for it is the pressure gradient from the lung to the capillary which is responsible for the passage of oxygen across the alveolar-capillary membrane. Likewise, the pressure gradient at the systemic capillary level is responsible for the oxygen passing from the peripheral capillary into the tissues. The recent availability of the Clark electrode to measure P02 directly in ar- terial blood makes this measurement much eas- ier. Normal values for arterial blood is 85 to 95, decreasing slightly in the older patient.
The diagnosis of hypoxemia presents many problems. The hypoxemic patient may demon- strate irritability, slight confusion, a loss of judg- ment, especially in dangerous situations, and per- haps even violent behavior. The only specific clinical sign of hypoxemia is cyanosis, which oc- curs only in the severely hypoxemic patient. The only accurate method of diagnosing this problem is arterial blood gas measurements.
What levels of hypoxemia may be dangerous?
Hypoxemia occurs at a P02 of about 60. Cyano- sis, which is the only definite sign of hypoxemia, occurs at a P02 of 50. As POL> continues to drop, tissue injury can be demonstrated with eleva- tion of SGOT and other enzymes. Finally, a P02 of 20 is incompatible with life. It should be re- membered that these are only guides — a normal person rendered acutely hypoxic may die with a P02 of 40. Conversely, a chronically hypoxemic patient might be fairly comfortable at the same POo.
TREATMENT OF HYPOXEMIA
The treatment of hypoxemia is rather easy. It simply involves increasing the oxygen con- centration the patient is breathing. Though there are many methods of administering the oxygen, the one most commonly available to most hos- pitals and physicians is the nasal cannula. Heated nebulizers furnishing 40 per cent oxygen concen- tration are also quite effective. Oxygen tents, for the most part, have no place in this condition, for it rather effectively isolates the patient which hinders effective respiratory care. Several prin- ciples should be emphasized. In the usual patient in respiratory insufficiency, only very small in- creases in the oxygen concentration are neces- sary. Usually oxygen at a rate of 2-3 liters per minute is entirely sufficient to prevent hypox- emia. Secondly, if a patient is hypoxemic, he re- quires oxygen continuously. This includes periods of eating, bathing, exercise and bathroom privi- leges. A third principle which should be em- phasized is the hazard of using too high a con- centration of oxygen. If a patient is in severe distress and is breathing from a hypoxic drive, then use of too high concentrations of oxygen may lead to further respiratory depression.
ELIMINATION OF C02
The elimination of C02 from the body is the second function of the lungs. The body is almost completely dependent on the lungs to carry out this function. As the result of aerobic metabolism, the body produces approximately 100 cc. of C02 per square meter of body surface area which amounts to about 200 cc. in a 70 kilogram man per minute. The body is dependent on alveolar ventilation to eliminate the C02: alveolar venti- lation = Produced^^63 c°2 . jf alveolar ventilation is decreased, then the body levels or partial pressure of C02 increases. Therefore, the PCOo
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in arterial blood is a function of alveolar venti- lation. The PC02 is directly proportional to the carbonic acid in the blood, and therefore, any rise in PC02 produces a rise in carbonic acid which therefore increases the hydrogen ion con- centration causing an acidosis.
This is related through the Henderson-Hassel- balch Equation: H*(aonomoles)=24 F^-Q(m(nieqf * Though this does not look like the familiar Hen- derson-Hasselbalch equation, it is another way of writing the equation. In looking at this it can be seen that an increase of the PC02 on the right side increases the hydrogen concentration. If the PC02 rises due to inefficient alveolar ventila- tion, then the patient will immediately develop a respiratory acidosis. The bicarbonate as de- picted in the formula is a function of the kid- neys. If the PC02 rises, then the kidneys func- tion to increase the bicarbonate in an effort to compensate for the acidosis and return the hy- drogen ion concentration or ph toward a more normal figure. The dynamics of the system are important. If respiration is cut in half, there is an immediate and sustained rise in minutes of the PC02. However, the kidney functions in a period of hours to days rather than minutes, and there- fore, compensation always lags in insufficient breathing.
C02 RETENTION
The clinical diagnosis of C02 retention is dif- ficult with many non-specific symptoms and signs. When significant C02 levels develop, the patient becomes increasingly drowsy, and as the PCOL» approaches 90, the patient will progress into a coma. Asterixis or a flapping tremor is not peculiar to liver disease alone. A rather typical flap may be seen in a patient in respiratory fail- ure. In the late stages of C02 retention, papil- ledema may be produced due to increased cerebral vasodilitation with increased blood flood. As in hypoxemia, the only true and accurate method of determining C02 states is the measurement of blood gas. Arterial blood is preferable, but venous blood may be sufficient in measuring the PC02, unlike hypoxemia where arterial blood is mandatory.
There are several principles which should be mentioned. Any elevation of PC02 means the patient is hypo-ventilating. Secondly, any eleva- tion of PC02 renders the patient hypoxemic. From the alveolar air equation: PACE = Fi,,2 P(B-H20) - PACCE x 1.2, a PC02 at a normal level of 40 reduces the oxygen from 140 in room
air to approximately 90 in the arterial blood; on the other hand, if the PC02 is 80, the C02 dis- places oxygen in the alveolar rendering the pa- tient much more hypoxemic.
Though the treatment of hypoxemia is easy with the administration of oxygen, the treat- ment of excess C02 retention is a more difficult clinical problem. If the cause of the respiratory insufficiency is acute, such as trauma, then venti- latory assistance is mandatory. In the emergency room, this might be the Ambu bag or mouth to mouth breathing. In the operating room, this may be the anesthesia machine. The IPPB ma- chines have enjoyed increasing popularity over the past several years. If the patient is alert and cooperative, perhaps a face mask or mouth piece will be sufficient, though one could use this only for limited periods of time.
TRACHEAL INTUBATION
If this should not prove an effective method, then tracheal intubation with an anesthesia type endotracheal tube would be in order. With proper care and due precautions, these tubes may be left in place for several days. As a general rule of thumb, if the tube is needed more than two days, conversion to a tracheostomy seems to be indicated; however, many cases have been treated with tubes for up to one week without undue problems. There are complications from the tubes, and these may present early or late. Finally, the tracheostomy may be indicated, and it is well recognized that these are not without complications also.
PRINCIPLES OF MANAGEMENT
In the more chronic problems such as emphy- sema, where the lungs are diseased, it may not be possible to return the patient to a normal blood gas state. Principles of management are slightly different. The first principle is to clean the tracheo-bronchial tree. If the patient is awake and coughing, then full advantage is taken of this. If he is too weak to cough, naso- tracheal suction may well be lifesaving. Various stimulants including ethamivan or dextroamphet- amine may increase his level of consciousness, and therefore improve his ventilatory effort. Var- ious physical therapy maneuvers also assist in more effective ventilation and drainage of the tracheo-bronchial tree. Finally, if these methods
1 5
JANUARY 1970
Respiratory Insufficiency / Shaw
in the chronic patient are ineffective, supported respiration with the respirators may be neces- sary.
THE IPPB MACHINE
Since the mid-1950s, when the value of IPPB machines was first recognized during the polio epidemic in the Scandinavian countries, much improvement has occurred. The cost of the IPPB devices ranges from $50 to $5,000 depending on the qualities and sophistication desired. The two main functions served by the IPPB machine are: (1) providing a deep breath and (2) pro- viding a vehicle for medication. Though it is not the purpose of this paper to discuss these ma- chines, certain principles should be mentioned.
The pressure necessary to ventilate a patient in various conditions differs. A pressure of 15 cm. Hl.O may be adequate for the obstructed patient with big overdistended lungs. On the other hand, the “stiff lung” as seen in pulmonary edema, pulmonary fibrosis, and other conditions may require pressures of 30-50 cm. Hv>0, and occasion- ally pressure of 120 cm. H>>0, may be necessary.
Secondly, despite the manufacturers’ claim of
delivering a 40 per cent 0_> concentration, this is not so, except on the newer and more expensive machines. The average CX concentration deliv- ered is between 50-60 per cent; so this, in effect, is uncontrolled CT. Compressed air rather than CX is adequate in most cases. Some type of moisture is necessary to keep from drying the tracheo-bronchial tree. A side arm medication nebulizer is completely insufficient. A main stream nebulizer or humidifier is most desirable.
Infection is increasingly recognized as a prob- lem. Gram negative organisms have been found as a cause of a necrosing pneumonitis. The source of infection, in most cases, is in the main stream nebulizers. Careful monitoring at regular intervals is essential in insuring the machines are free of bacterial contamination.
SUMMARY
In summary, many important and improved changes in the respiratory insufficiency prob- lem have come about in the past several years. All of these changes are based on improved un- derstanding of the pathophysiology of the prob- lem. If these pathophysiology changes are under- stood, then a more rational approach to therapy is possible. ***
440 East Woodrow Wilson (39216)
RESTFUL REST ROOM
Stopping at a rural service station, the motorist asked, “Do you have a rest room?”
“Nope,” said the attendant. “When any of us git tired we jes sit on one of them oil drums.”
16
JOURNAL MSMA
Cancer Quiz
Cancer Committee University Medical Center Jackson, Mississippi
This feature, consisting of review questions re- lated to the cancer field, was prepared by the Cancer Committee of the University Medical Center. Answers appear on a separate page.
Questions from readers related to these re- view questions may be submitted to the Edi- tors of the Journal for forwarding to the com- mittee. Each will receive a personal reply. Suit- able questions from readers will be considered for publication. This initial presentation relates to general cancer statistics, based on data pub- lished by the American Cancer Society.
Comment and suggestions are invited from readers. — The Editors.
1 ) In the United States, cancer deaths represent
approximately what per cent of total deaths:
a) 5%
b) 15%
c) 25%
d) 35%
2) These cancer deaths represent a total num- ber in the range of:
a) 100,000
b) 300.000
c) 500,000
d) 700.000
3) The annual U. S. death total, if expressed
in deaths per unit of time, would be:
a) One death per 1 minute
b ) One death per 2 minutes
c) One death per 5 minutes
d) One death per 10 minutes
4) The mortality rate, male to female is:
a) 50% men/50% women
b) 45% men/55 % women
c) 45% men/45 % women
d) 60% men/40% women
5) The two leading causes of cancer deaths in the U. S. A. are:
a) breast cancer
b ) cervix cancer
c) lung cancer
d) rectal-colon cancer
6) The two leading causes of cancer deaths among American men are:
a) lung cancer
b ) rectal-colon cancer
c) Hodgkin's disease
d ) stomach cancer
7 ) The leading two causes of cancer deaths among American women are:
a) lung cancer
b) breast cancer
c) cervix cancer
d) rectal-colon cancer
8) Incidence data shows the most common can- cer is:
a) lung cancer
b ) breast cancer
c) cervix cancer
d) skin cancer
9) Approximate annual total cancer deaths in Mississippi is:
a) 1,000 per year
b) 2,000 per year
c) 3,000 per year
d) 4,000 per year
10) If your patient community consists of 5,000 people, the approximate number that will be under cancer care during the next year is:
a) 10
b) 20
c) 30
d) 50
(Answers on page 49)
JANUARY 1970
17
Radiologic Seminar XCI: Tracheoesophageal Fistula
WALTER T. COLBERT Natchez, Mississippi
Tracheoesophageal fistula (TEF) occurs once in 3000 births, and in over 95 per cent of instances is associated with atresia of the esopha- gus. This anomaly is one of the most frequent congenital defects, which, if left untreated, will be uniformly fatal in the neonatal period.
There are two conditions which may herald the birth of a child with esophageal atresia and tracheoesophageal fistula-polyhydramnios and prematurity. Commonly associated anomalies that should be recognized at birth are congenital heart defects, imperforate anus, arm and hand anomalies, and clefts of the lip and palate. In babies born of mothers with polyhydramnios a routine part of the neonatal examination must in- clude the passage of a nasogastric tube and veri- fication of its presence in the stomach by x-ray. The same procedure should be followed in the routine examination of premature babies or those born with any of the above mentioned malforma- tions.
In a majority of infants with esophageal atresia and TEF anomalies the diagnosis will be sug- gested by the following signs. Apparently exces- sive mucus will usually be the first clinical sign, as all of the mucus must be regurgitated in in- stances of esophageal atresia. These infants will
Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, Natchez General Hospital.
also cough, choke, and may become cyanotic when fed. These findings will frequently be no- ticed by personnel in the nursery. It is important that the diagnosis be made promptly, as the pre- vention of pneumonitis by appropriate therapy is mandatory if these infants are to be salvaged.
The diagnosis can be established definitely by failure of passage of a radiopaque catheter into the stomach. If the tube cannot be passed into the stomach and verified as to position by radio- logic means, a small amount of opaque material can be introduced into the catheter and the site of esophageal atresia will be demonstrated. In those instances where there is no associated esophageal atresia — a relatively small percent- age— the diagnosis will depend upon actual con- trast filling of the communication between the esophagus and trachea. This can be accomplished by the injection of opaque material through a catheter in the upper esophagus, with care being taken to avoid spillage of the opaque material over the epiglottis.
CASE I — This two day old male infant was noted by the nursery personnel to cough, choke and become cyanotic whenever feeding was at- tempted. TEF was suspected clinically, and a catheter was passed easily into the stomach ex- cluding the presence of esophageal atresia. Opaque material (micropaque) was then intro- duced through an esophageal catheter, and a di- rect communication between the upper esophagus and trachea was demonstrated. The patient was
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Case I — Figure 1. Oblique views of the barium-filled esophagus demon- strate beginning, and subsequent en- thusiastic filling of the tracheobron- chial tree through the tracheo-esopha- geal communication (arrow). Opaque material was introduced into the esophagus using a balloon catheter in order to prevent aspiration of opaque material over the epiglottis.
Case I — Figure 2. Chest film made immediately following the fluoroscopic procedure: an unintended, but normal bronchogram is noted. The lung fields were grossly clear in approximately 72 hours.
JANUARY 1970
19
HEH H02b
Case II — Figure 1 . Oblique views of the chest with contrast material in the esophagus demonstrate a blind pouch, with no communication with the tracheobronchial tree. The patient did not aspirate any of the opaque material over the epiglottis.
Case II — Figure 2. A routine chest and abdomen film demonstrate rela- tive over-expansion of the lung fields, and considerable gas throughout the gastrointestinal tract. This finding in- dicated a definite communication be- tween the tracheobronchial tree and GI tract below the site of obstruction demonstrated on the contrast study.
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treated surgically, with primary closure of the fistulous communication. This type of tracheo- esophageal fistula comprises only 4 per cent of the TEF anomalies.
CASE II — This new born female infant was noted to have “excessive mucus” immediately after birth. It was not possible to pass a catheter into the stomach, and opaque material intro- duced into the pharynx demonstrated a blind pharyngo-esophageal pouch, with no communi- cation between the atretic esophagus and the tracheobronchial tree. A film of the chest and abdomen, however, demonstrated over-expan- sion of the lung fields, and considerable gas throughout the entire GI tract. This finding indi- cated a definite communication of the GI tract with the tracheobronchial tree distally. These findings were verified at the subsequent surgical proce- dure. This type of tracheoesophageal fistula com- prises approximately 87 per cent of the TEF anomalies.
The two cases noted above are fairly typical examples of the TEF anomalies that present themselves in the immediate neonatal period, and which can be diagnosed promptly by roent- genologic means.
SUMMARY
Tracheoesophageal fistula and esophageal atresia are neonatal emergencies which can be diagnosed promptly by roentgenologic means. While uncommon in occurrence, prompt recog- nition is necessary for survival of these infants. Pneumonitis remains the usual cause of a fatal outcome in these anomalies, but this complica- tion can be prevented by prompt recognition of the fistula and appropriate treatment. ***
Jefferson Davis Memorial Hospital (39120)
BIBLIOGRAPHY
Holder, Thomas M., and Ashcraft. Keith W. : Current problems in surgery. Chicago. Yearbook Medical Publishers, Inc., 1966.
PROFESSIONAL GRATUITY
Called by his draft board, a young man was examined by his family doctor who happened to be on the board. He passed easily and was inducted, which burned him up.
Next day he phoned the doctor and said. “You're one heck of a doctor. It’s funny you always found something wrong with me when I was paying to visit you!"
JANUARY 1970
21
The President Speaking
‘Needed Now’
JAMES L. ROYALS, M.D.
Jackson, Mississippi
The first three days in December the AMA held its annual clinical convention in Denver. In addition to your delegates, sev- eral of your officers attended. On Saturday, preceding the regular meeting, there was an all day conference on peer review. This was a most enlightening conference, which revealed to us that prob- lems physicians face are more or less the same throughout our nation.
The afternoon part of this meeting was composed of two dem- onstrations by peer review committees, one a committee from a hospital staff as it functioned in reviewing the in-hospital activities of its staff members and the other a peer review committee from a county medical society as it dealt with problems relating to a broader aspect of our health care system. These interesting demonstrations revealed the degree to which organized medicine in other areas of the country are dealing with pressing and some- times painful problems within its own ranks.
It is essential, if medicine hopes to continue as a free enter- prise, to improve its own peer review so as to assure a continuing up-grading of quality medical service. I find that Mississippi is behind the other states in the application of peer review and urge that medical staffs and component medical societies move rapidly ahead in this urgently needed area of self-analysis.
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JOURNAL MSMA
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
VOLUME XI. NUMBER 1 January 1970
Medicaid in Mississippi: A Bare Bones Beginning
I
The first day of 1970 will be more remark- able for eight hours of bowl games on television, family gatherings, and a few headaches from the festivities of New Year’s Eve than for the incep- tion of the $33.7 million Medicaid program in Mississippi. For all intent and purpose, the date is so much statutory rhetoric, because the pro- gram will not be fully operational before spring or perhaps summer. It is a bare bones beginning.
The Mississippi Medical Assistance Act of 1969, House Bill 2 of the Extraordinary Session of the Legislature, is the legal mouthful for Medicaid. Its birth pains were harsh as the so- lons debated with spirit — and sometimes acri- mony— from July 22 through Oct. 11. It ex- ists only because of administration leadership, an understanding of what had to be done by a majority of legislators, and the support of the health care team.
It is a complicated law which implements the most complex health care program ever devised by the Congress. The proof of this pudding shows up in the misunderstanding about it dur- ing debate in the Legislature. And beyond this.
there were out-and-out hostile efforts openly ex- erted to cloud the issues and defeat the bill. But this is mostly in the past tense, as the mecha- nism of state government has meshed in heroic effort to get the program off the ground in a mat- ter of two and one-half months. Almost any workable result has got to go down in the history books as a compliment to the John Bell Williams administration and the newly created Mississippi Medicaid Commission.
The program director. Dr. Alton B. Cobb of Jackson, has assembled the nucleus of a compe- tent staff, initiated communications and working agreements with providers, coordinated with oth- er state agencies, and begun the task of building the substantial fiscal machine necessary to make as many as 2 million payments per year.
II
For a minimum of three months, only six ser- vices will be activated:
— Inpatient hospital services.
— Outpatient hospital services.
— Other laboratory and x-ray services.
— Skilled nursing home services.
— Physicians’ services.
JANUARY 1970
23
EDITORIALS / Continued
— Periodic screening and diagnostic services.
Seven other categories of services under the program are, for the moment, deferred because of time demands in solving staggering imple- mentation problems. These are home health ser- vices for beneficiaries eligible for skilled nursing home services, emergency ambulance service or- dered by a physician or law enforcement officer, legend drugs and insulin, sharply limited dental services, eyeglasses following eye surgery, inpa- tient hospital services for those over age 65 in an institution for tuberculosis or mental disease, and care and services provided in Christian Sci- ence sanatoria.
In scope, amount, and duration, services are generally limited by frequency of utilization, ex- cept for physicians’ services which are addi- tionally limited by dollar amounts. Inpatient hos- pital care is provided for 20 days per fiscal year with an additional 20 days available on review, recertification, and approval by the utilization review mechanism. Outpatient hospital care is limited to 30 visits per fiscal year.
Stays in nursing homes beyond 90 days must pass review criteria, and while specific limitations on laboratory and x-ray services are not men- tioned, the labs must be certified under Title XVIII (Medicare).
Ill
Physicians will be compensated for services rendered in the hospital, nursing home, office, patient’s home, or elsewhere. Ordinarily, hospital visits are limited to one per day, and the pro- gram will pay for a maximum of 36 nursing home visits per year.
Limitations on home and office visits are not mentioned, but the Medicaid Commission has plans for closely supervised utilization review. Diagnostic laboratory services performed in the physician’s office are limited to hematocrit, hemo- globin, routine urinalysis, and WBC.
The Medicaid law prescribes payment for phy- sicians under the Mississippi Blue Shield F-300 fee schedule, and it is neither complete nor rela- tive. Generally, the schedule provides payment around the 50th to as much as the 60th per- centiles. For the many procedures not covered by the F-300, the California Relative Value Index of 1964 will be used with a $4 per point conver- sion coefficient. In some instances, this will per- mit professional compensation at as much as the 70th percentile.
By anybody’s measurement, these are sub-
standard fees, and this has been the pattern for Medicaid nationally in 1969 following the HEW-imposed fee freeze. Participation is volun- tary, of course, and those participating should charge their usual and customary fees exactly as charged to private patients, regardless of what they receive in payment.
Charges at the usual and customary level are crucially important if we are to avoid a distorted profile of fee patterns prevailing in Mississippi. For many years, some physicians charged only what low option care financing plans would pay on the shaky assumption that they were expedit- ing payment of what they would get anyway. This practice actually worked against the phy- sician in the matter of his receiving fair profes- sional compensation, because there was simply nothing on the books to prove that the real charges were greater than the parsimonious al- lowances of the financing mechanism.
IV
It is fair to say that Medicaid in Mississippi is in a probationary period as it moves onto the scene to finance health care for about 9 per cent of the state’s population. For such a massive task, it is indeed a bare bones program. To make it a viable mechanism as visualized by the associ- ation’s House of Delegates in approving it on two occasions will demand patience, leadership, and not a little sympathetic understanding.
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JOURNAL MSMA
The physician is not being fully compensated for his services under the program — not na- tionally nor in Mississippi. Through June 30. 1969. total payments to physicians under all Medicaid programs then operational amounted to 11 per cent of all combined state and federal funds expended, while 89 per cent had been paid to hospitals, nursing homes, pharmacists, and all other care sources. Two principal and opposite arguments about professional compen- sation have been noted in Mississippi:
— When the state buys a tire for a state- owned vehicle, it pays the price of a tire. When a shovel is purchased for the Forestry Commis- sion. the state pays out the price of a shovel. Hence, when the state purchases an appendec- tomy, it should pay the going price.
— Since 1936 when the State Hospital Com- mission program was enacted, physicians have received nothing for their services to the indigent in Mississippi and were, in fact, forbidden to charge, accept payment, or in any manner be compensated. Under Medicaid, at least a be- ginning has been made with half a fee or a little more.
The association has spoken frankly in this connection: Physicians should be compensated for services actually rendered with payment of true usual and customary fees. This will be a goal in any program — not just Medicaid — which falls short. But it does not mean that Medicaid will be ignored or that the association's increas- ing effectiveness in peer review will be denied the program. Nor does this infer that support is grudgingly given, because the word of the House of Delegates is the association's pledge and bond. The practicing physician asks only that a fair shake be afforded him. and he will carry out his dedication in partnership with his state. — R.B.K.
The Old Chit-Chat Gets a Facelifting
The state medical association’s oldest existing and continuing publication, the Newsletter, has turned up with its third facelifting. Beginning with this issue of the Journal, the Newsletter goes to a three-page format as more or less the first and last words in each issue. The third page, entitled “In Conclusion.'’ will be the last page in each issue.
Newsletter is 19 years old. having made its initial appearance as a single mimeographed page in 1951 which was published twice month- ly. A year later, it showed up as a four-page monthly publication sent to every member and continued uninterrupted until December 1959. When the first issue of the Journal was published in January 1960, Newsletter appeared as a two- page bound insert in the front of the book.
After 10 years, the chatty sheet becomes an integral part of the Journal on three printed pages. The Editors and Committee on Publica- tions feel that the new format will give more flexibility, increase readership, and assist in pro- duction. The insert was printed at Jackson and shipped to the Journal printers, sometimes with teeth-gnashing results. For example. News- letter was missent by the post office to the wrong city twice in 1969 and completely lost once some- where in that rain. snow, sleet, and gloom of night through which the U. S. mail must traverse.
As with each and every feature, article, and regular department in the Journal, the News- letter belongs to the membership. Suggestions, criticism, and comment are invited on the new format. As for the retiring two-pager, appreci- ation is expressed for letters, calls, and com- ment— both kinds — over the past decade. — R.B.K.
Mandatory Licensure For Mississippi Nurses
The state medical association has a new pol- icy on licensure of nurses, a carefully developed course of action which is the product of open de- bate, serious study, and multi-level review and approval by constitutional bodies.
Subject to the actual bill introduced in the 1970 Regular Session of the Legislature as to form and content, the association approves man- datory licensure of nurses in Mississippi.
At the 101st Annual Session in May 1969. the House heard sincere pro and con debate on this issue. Recognizing it as a matter requiring further study and mature consideration, the House recommitted the issue to the Council on Medical Service. The council, in turn, met and reviewed the matter, assigning it to the Committee on Nurs- ing. one of the council’s committees devoted to one of its many specialized fields.
25
JANUARY 1970
EDITORIALS / Continued
The committee made studies, met with rep- resentatives of the nurses association, took the pulse of hospitals, and considered views of phy- sicians. Through these deliberations, the new pol- icy was carefully shaped with virtually no rami- fication neglected in the process.
The committee first looked at licensure for all health care and health-related professions. Generally, such licensure is a function of the states and has these characteristics:
— It is issued to an individual rather than to a company, corporation, or impersonal entity.
— It authorizes the individual so licensed to engage in a profession or occupation, usually employing a special or distinctive identifying title.
— It is granted on one or more of the follow- ing conditions: Education or training minimums, apprenticeship or practice, proficiency or knowl- edge, good character, honorable intent, and at- tainment of a stated age.
Licensure of an occupation or profession is either mandatory or permissive. Of 13 health care and health-related professions and occupa- tions licensed in Mississippi, nine are mandatory (as in the case of physicians and dentists), while four are permissive. Mandatory licensure re- quires that the individual practicing the profes- sion or engaging in the occupation be licensed and prohibits all others from doing so. Permis- sive licensure permits only those licensed to use a particular title or designation relating to the profession or occupation, but others are not pro- hibited from working in the field as long as they do not use the protected title or designation.
Nurses have mandatory licensure in 42 state jurisdictions for the R.N. and permissive licen- sure in nine, including Mississippi.
Mississippi nurses have long sought manda- tory licensure. Such a law was enacted in 1958 but vetoed by the then-Governor because of the composition of the examining board and not, ac- cording to the association’s understanding, be- cause of the mandatory aspects. Arguments over the issue have nearly always centered on the crucial matter of whether such a law would ex- acerbate the already serious shortage of nurses in the state.
The draft bill which was examined by the as- sociation's official bodies exempts from licen- sure “any person functioning under proper su- pervision as nursing aids, attendants, orderlies, and other auxiliary workers in private homes, offices, hospitals, nursing or rest homes, or insti- tutions.”
The draft also omits the two physician-mem- bers from the Board of Nurse Examiners. The proposed board would consist of five R.N.’s and two L.P.N.’s, and the latter would not be per- mitted a vote except on matters relating to li- censed practical nurses. The policy of the medi- cal association expresses serious reservations over the composition of the proposed board “not necessarily related to the physician-members.” The policy expresses concern for a “balance in the exercise of this power by inclusion of health team representatives other than nurses as full voting members.”
But in giving approval to the principle of mandatory licensure for nurses, the policy has been carefully reviewed by a committee, an elected council, and the Board of Trustees. It is an expression of concern and good faith by the physicians of Mississippi who have reserved the right to speak up in the forging of any law which may be enacted. — R.B.K.
Jackson Chamber Honors Health Care Team
A very special year-end occasion honored medicine in Mississippi as the Jackson Cham- ber of Commerce made health care and care providers the theme of its 1969 membership meeting. Although the Jackson Chamber is typi- cal in being oriented toward business and indus-
“Sorry we can’t discharge you from the hospital today , Mr. Wilkins . . . it’s far too windy outside.”
26
JOURNAL MSM A
try, the capital city organization has strong med- ical orientation, too.
The 3,000-plus member group has long recog- nized that Jackson is a primary medical cen- ter and has given strong support to develop- ment of medical facilities in the capital. The chamber points out with pride that medical care is the second biggest “industry” in the city, sec- ond only to state government in total employ- ment. An estimated 8,000 individuals are in- volved full time in health services and supportive work.
The membership meeting, attended by 800 at a gala banquet, singled out for recognition physi- cians, dentists, hospitals, nursing homes, pharma- cists, and health services supply sources. One hundred twenty-five Jackson physicians are on the active membership rolls of the chamber which also boasts 33 dentists. Well represented also are leaders from hospitals, nursing homes, wholesale and retail drug firms, medical supply sources, and dental laboratories.
Although the state feels the pinch of health service personnel shortages, it benefits from a continuing maximum effort by its health care team. In turn, these providers of services are grateful for recognition by civic leadership. Each needs the other in working for a better state. —R.B.K.
Our Environment Is at Stake
If the fight against pollution is lost, then we also lose the productive environment in a nation of plenty. And the latest word is that we are los- ing the fight.
The Comptroller General of the United States, Elmer B. Staats, has reported to the Congress that $5.4 billion — that’s $1.2 billion federal dol- lars and a hefty $4.2 billion from the states — spent on water pollution control has been largely dissolved into the effluent and wastes that fill our rivers, streams, and land-locked bodies of water.
Mr. Staats says that some good has come of the monumental effort, but pollution has increased in spite of the expenditures. As waste control projects are completed, more sources of pollution crop up. In the 13 years of the life of the Federal Water Pollution Control Administration, the ton- nage of waste discharge into rivers and streams has actually increased. Worse yet are the inade- quate treatment systems which may mask the problem.
The Comptroller General believes that pres- ent programs are little more than a shotgun ap- proach, and he hints that some funds have been dumped into the pork barrel rather than the sewage lagoon. There is also an overtone of in- adequate state law and enforcement against mu- nicipal and industrial pollution sources.
Mississippi was late coming into the program, and we have a commission which is less than two years old. But the important thing is that something is being done about a serious health and environmental safety problem. It’s not a matter of shackling industry or of making produc- tion uneconomical. Industry can no more survive in a polluted environment than can its workers and consumers of its products.
While Mr. Staats was addressing himself to the economic aspects of the problem which is his job in reporting to the Congress, he demon- strated clearly that he understands the health aspects of it, too. With stern realism, the report recommends that no federal money be plunked down for antipollution projects until their effec- tiveness is assured.
All of this means that the task of creating a safer environment is everybody’s job under well- enforced laws. Pollution is a health problem of undefined dimensions, but we can easily see that it is massive enough to threaten our very existence. We’d better do something about it — and soon. —R.B.K.
January 19-23
CANCER CHEMOTHERAPY INTENSIVE COURSE
University Medical Center, Jackson January 19, 20, 21, 22, 23, 1970, beginning at 8 a.m.
Sponsored by The University of Mississippi School of Medicine, with the support of the Mississippi Regional Medical Program
Participants:
Warren N. Bell. M.D., professor of clinical lab- oratory sciences and chairman of the depart- ment and associate professor of medicine. The University of Mississippi School of Medicine G. D. Deraps. M.D., instructor in medicine. The University of Mississippi School of Medicine
JANUARY 1970
27
POSTGRADUATE / Continued
This one-week intensive course will com- bine lectures, group discussions, case presenta- tions and actual clinical evaluation and man- agement of patients with the most common malignancies. Course content will include meth- ods for office screening, tumor staging, natural history of disease, indications and treatment of various malignancies with chemotherapy and radiotherapy.
February 9-13
RADIOLOGY INTENSIVE COURSE University Medical Center, Jackson February 9, 10, 11, 12, 13, 1970, beginning at 8 a.m.
Sponsored by The University of Mississippi School of Medicine, with the support of the Mississippi Regional Medical Program
Participant:
Robert D. Sloan, M.D., professor of radiology and chairman of the department. The Uni- versity of Mississippi School of Medicine
The one-week intensive course will include practical observations of radiologic procedures in the diagnostic, therapeutic, and isotope areas, as well as sessions dealing with equip- ment, techniques, artefacts, and radiation safe- ty. Registrants will participate in numerous diagnostic conferences demonstrating practical points of radiographic interpretation, stressing both the value and limitations of clinical radi- ology.
Registration in both intensive courses is lim- ited to five physicians from the class of 20 en- rolled in the Mississippi Postgraduate Insti- tute in the Medical Sciences, a Mississippi Re- gional Medical Program-supported project de- signed by the University of Mississippi Medi- cal Center and the Mississippi State Medical Association.
CIRCUIT COURSES
Southwestern Circuit
McComb — January 6 — Session 2, Southwest Mississippi General Hospital, 7 p.m. Session 2 — Hyperthyroidism
Medical Management, Dr. Herbert Lang- ford
Surgical Management, Dr. Harvey Johns- ton
Southern Circuit
Biloxi — January 7 — Session 1, Howard Me- morial Hospital, 6:30 p.m.
Gulfport — February 4 — Session 2, Gulfport Memorial Hospital, 6:30 p.m. Hattiesburg — January 8 — Session 1; Febru- ary 5 — Session 2, Forrest General Hos- pital, 6:30 p.m.
Session 1 — Diagnosis and Management of Anemia
In Adults, Dr. Guy Gillespie In Children, Dr. Robert E. Carter Session 2 — Diagnosis and Management of Malignant Skin Lesions Dermatologic Approach, Dr. James G. Thompson
Surgical Approach, Dr. J. Manning Hud- son
Eastern Circuit
Columbus — January 27 — Session 1, Lowndes County General Hospital, 6:30 p.m. Session 1 — Carcinoma of the Cervix
Radiologic Approach, Dr. Bernard Hick- man
Surgical Approach, Dr. Richard Boronow FUTURE CALENDAR
January 6, 1970
Circuit Course, McComb
January 7
Circuit Course, Biloxi January 8
Circuit Course, Hattiesburg January 19-23
Cancer Chemotherapy Intensive Course
January 27
Circuit Course, Columbus February 4
Circuit Course, Biloxi February 5
Circuit Course, Hattiesburg February 9-13
Radiology Intensive Course
February 11
Seminar on Back Pain
February 17
Circuit Course, Natchez February 24
Circuit Course, Columbus
JOURNAL MSM A
March 2-6
Renal Disease Intensive Course March 4
Circuit Course, Biloxi March 6
Renal Disease Seminar March 12
Circuit Course, Hattiesburg March 16-20
Cardiology Intensive Course Stroke Intensive Course
April 1-3
Cardiovascular Seminar April 7
Circuit Course, McComb April 16
Mississippi Thoracic Society, Jackson April 21
Circuit Course, Columbus May 11-14
Mississippi State Medical Association
RMP Awards Cardiopulmonary Grant
The Mississippi Regional Medical Program has awarded a nine-month grant of $38,988 to the Mississippi Heart Association for a cardiopul- monary resuscitation project.
Aimed at training members of the health team in approved techniques of cardiopulmonary re- suscitation, the program also seeks to broaden the development of continuous inservice instruc- tion programs in each regional hospital, nursing home and extended care facility.
Erratum
Through an inadvertent binding error, pages 547-550 were omitted from some copies of the December 1969 Journal, Vol. X, No. 12. The missing pages are part of CPC XCV.
We apologize to our author. Dr. William B. Wilson of Jackson, and to our readers. Those having received copies with missing pages are requested to inform the Editors by postal card, and a complete reprint of the article will be re- turned— with an unused postal card.
Cftest
HOSPITAL
(Formerly Hill Crest Sanitarium)
7000 5TH AVENUE SOUTH Box 2896, Woodlawn Station Birmingham, Alabama 35212
Phone: 205-836-7201
A patient centered independent hospital for intensive treatment of nervous disorders . . .
Hill Crest Hospital was estab- lished in 1925 as Hill Crest Sanitarium to provide private psychiatric treatment of ner- vous or mental disorders. Indi- vidual patient care has been the theme during its 44 years of service.
Both male and female pa-
tients are accepted and depart- mentalized care is provided ac- cording to sex and the degree of illness.
In addition to the psychiatric staff, consultants are available in all medical specialities.
MEDICAL DIRECTOR:
James A. Becton, M.D., F.A.P.A.
CLINICAL DIRECTORS:
James K. Ward, M.D., F.A.P.A. Hardin M. Ritchey, M.D., F.A.P.A,
HILL CREST is a member of:
AMERICAN HOSPITAL ASSOCIATION . . . . . . NATIONAL ASSOCIATION OF PRI- VATE PSYCHIATRIC HOSPITALS . . . ALABAMA HOSPITAL ASSOCIATION . . . BIRMINGHAM REGIONAL HOSPITAL COUNCIL.
Hill Crest is fully accredited by the Joint Commission on Accreditation of Hospitals and is also approved for Medicare pa- tients.
C/test
HOSPITAL
BIRMINGHAM, ALABAMA
JANUARY 1970
29
ORGANIZATION / Continued
Blair E. Batson and Janice Redd, both of Jackson and UMC, attended the fall meetings of the Southern Society for Pediatric Research in Richmond, Va.
G. Lacey Biles of Sumner spoke at a recent District Four Heart Association meeting in Clarksdale. Also speaking was Walter Taylor of Clarksdale who talked on diet and heart dis- ease.
Robert E. Blount of Jackson and UMC met with the American Rheumatism Association in Tucson. Ariz. Dec. 5-6.
L. H. Bounds is serving his second term as pres- ident of the Meridian Symphony Society Board.
John Bower of Jackson and UMC recently spoke to the Corinth Chapter of the Kidney Foundation of Mississippi about kidney disease and the treatments including transplanting and the artificial kidney machine.
Ralph H. Brock of McComb announces the re- moval of his office to 150 Marion Avenue.
Raymond W. Browning of Greenwood an- nounces the removal of his office to his newly constructed clinic at 1317 River Road.
Paul B. Brumby of Lexington recently addressed the annual convention of the Mississippi Fed- eration of Licensed Practical Nurses, Inc. at the Hotel Heidelberg in Jackson.
Ten Jackson physicians were cited as health leaders by the Jackson Chamber of Commerce at its annual meeting in November. Those spot- lighted in the “Salute to Health Care Facilities and People” were Robert Carter, David Wil- son, James L. Royals, William O. Barnett, James Hendrick, William Lotterhos, Alton Cobb, W. L. Jaquith, Eric McVey, and Hugh Cottrell.
Robert E. Carter, UMC dean and director, participated in a National Volunteer Leadership Conference of the National Foundation-March of Dimes in San Diego in December.
Walter Crawford of Tylertown spoke to the
Tylertown Rotary Club during National Family Health Week.
Robert L. Donald of Pascagoula has been named State Chairman for Jaycee International Medical Supplies Program. The J.I.M.S. Program was conceived and initiated by Dr. Donald.
William E. Eggerton of Meridian announces the opening of his offices at 1 1 2-24th Avenue for the practice of dermatology.
Ira E. Gaddy, Jr. of Mississippi City has been appointed to the board of trustees of Memorial Hospital in Gulfport. Dr. Gaddy has the distinc- tion of being the first physician appointed to the board of trustees.
R. F. Gates of Gulfport has assumed the presi- dency of the Coast Counties Medical Society. New president-elect is Paul Horn of Biloxi and retiring president is A. K. Martinolich of Bay St. Louis. E. T. Riemann, Jr. of Gulfport was named vice president, and Hal Cleveland of Gulfport is secretary-treasurer.
Hannelore H. Giles of Hattiesburg announces the opening of her office for the practice of cardi- ology at 990 Hardy Street.
Raymond F. Grenfell and James L. Royals of Jackson attended the AMA clinical meeting in Denver last month.
Arthur C. Guyton, Harper K. Hellems, Herbert G. Langford, Richard G. Hutch- inson, Gaston Rodriguez, and David G. Wat- son, all of Jackson and Joe M. Ross of Vicks- burg attended the American Heart Association scientific sessions and annual assembly in Dal- las.
Carl Hale of Hattiesburg recently discussed radiological services at Forrest General Hospital at a Hub City Kiwanis Club meeting at the Red Carpet Inn.
G. Swink Hicks of Natchez has been re-elected to serve a three year term on the Board of Trus- tees of the Mississippi Baptist Hospital.
Gerald Hopkins of Oxford recently spoke to the District Six meeting of the Mississippi Heart Association in Grenada. He was introduced by Gaines L. Cook of Grenada, Medical Repre- sentative of Grenada County.
Jerry W. Iles of Natchez presented a biograph- ical summary of Dr. John Wesley Monette, the first physician to become a member of the Mis- sissippi Hall of Fame, at a recent meeting of
30
JOURNAL MSM A
ill
St
m
is
e
]
Achrocidin Tablets and Syrup
Tetracycline HC1— Antihistamine— Analgesic Compound
Each tablet contains: ACHROMYCIN® Tetracycline HC1 125 mg.; Phenacetin 120 mg.; Caffeine 30 mg.; Salicylamide 150 mg.; Chlorothen Citrate 25 mg.
ACHROCIDIN Tetracycline HC1— Antihistamine— Analgesic Compound Tablets and Syrup are recommended for the treatment of tetracycline-sensitive bacterial infection which may complicate vasomotor rhinitis, sinusitis and other allergic diseases of the upper respiratory tract, and for the concomitant symptomatic relief of headache and nasal congestion. For children and elderly patients you may prefer caffeine-free ACHROCIDIN Syrup. Each 5 cc contains: ACHROMYCIN Tetracycline equivalent to Tetracycline HC1 125 mg.; Phenacetin 120 mg.; Salicylamide 150 mg.; Ascorbic Acid (C) 25 mg.; Pyrilamine Maleate 15 mg.
Contraindications: Hypersensitivity to any component.
Warning: In renal impairment, since liver tox- icity is possible, lower doses are indicated; dur- ing prolonged therapy consider serum level determinations. Photodynamic reaction to sun- light may occur in hypersensitive persons. Photosensitive individuals should avoid expo- sure; discontinue treatment if skin discomfort occurs.
Precautions: Drowsiness, anorexia, slight gas- tric distress can occur. In excessive drowsi- ness, consider longer dosage intervals. Persons
on full dosage should not operate vehicles. Nonsusceptible organisms may overgrow; treat superinfection appropriately. Treat beta- hemolytic streptococcal infections at least 10 days to help prevent rheumatic fever or acute glomerulonephritis. Tetracycline may form a stable calcium complex in bone-forming tissue and may cause dental staining during tooth development (last half of pregnancy, neonatal period, infancy, early childhood).
Adverse Reactions: Gastrointestinal— anorexia, nausea, vomiting, diarrhea, stomatitis, glossi- tis, enterocolitis, pruritus ani. Skin— maculo-
papular and erythematous rashes; exfoliative dermatitis; photosensitivity; onycholysis, nail discoloration. Kidney— dose-related rise in BUN. Hypersensitivity reactions— urticaria, angioneurotic edema, anaphylaxis. Intracranial —bulging fontanels in young infants. Teeth— yellow-brown staining; enamel hypoplasia. Blood— anemia, thrombocytopenic purpura, neutropenia, eosinophilia. Liver— cholestasis at high dosage.
Upon adverse reaction, stop medication and treat appropriately.
LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 10965
534-9
PERSONALS / Continued
the Natchez Historical Society at Coyle House on Wall Street.
William E. Lotterhos of Jackson addressed the North Jackson Kiwanis Club in observance of National Family Health Week. His topic was the family physician today. Dr. Lotterhos is president-elect of the American Academy of General Practice.
Thomas Stanley Martin of Hattiesburg has been elected to active membership in the Amer- ican Academy of General Practice. Dr. Martin is director of student health services and the medi- cal clinic at the University of Southern Mis- sissippi.
Albert Meena of Jackson has been elected as one of nine directors of the Better Business Bu- reau for a three year term.
Shelby W. Mitchell of Laurel is serving as acting health director of Harrison County. The post has been vacant since Hurricane Camille. Dr. Mitchell’s regular assignment is health of- ficer of Jones, Jasper, and Covington Counties.
Steven L. Moore of Jackson has been appoint- ed Mississippi’s new comprehensive health plan- ning director by Gov. John Bell Williams. Dr. Moore was formerly director of the division of local health services in the State Board of Health.
William G. Munn has moved into his new medical clinic at the corner of East Jackson Ave- nue and Oak Street in Mendenhall.
Dudley H. Mutziger of Natchez announces the removal of his offices from 729 North Pearl Street to the Medical Arts Building on Sgt. Prentiss Drive.
Glenn T. Pearson of Hattiesburg has been elected secretary-treasurer of the Hattiesburg Area Chamber of Commerce.
Curtis D. Roberts of Brandon has been elected vice-chief of the medical staff of Rankin Gen- eral Hospital. Roland Samson was elected to a three-year term on the executive committee, and Robert Rester was named to the hospital’s ac- tive staff.
Maurice Taquino of Biloxi was elected to the board of directors of Harrison County Private School Foundation at its annual meeting in Gulf- port.
Norman W. Todd of Newton recently attended an Air Medical Examiner Flight Surgeon Sem- inar in Oklahoma City. Dr. Todd has been a sen-
3 2
ior medical examiner for all types of commercial and private pilots for 10 years.
Richmond Sharbrough of Vicksburg has been elected vice president of the newly organized Men’s Golf Association of that city.
Guy T. Vise of Meridian is serving as chairman of the Operation Drug Alert committee of the Meridian Kiwanis Club. The program is de- signed to alert Meridian people to the dangers of drug abuse.
David G. Watson of Jackson participated in a symposium on the Natural History and Progress in Treatment of Congenital Heart Disease Dec. 3-7 in Toronto, Canada.
David B. Wilson of Jackson and UMC attended the Washington, D. C. meeting for a Maryland- D. C.-Delaware Hospital last month.
. Armstrong, George Glaucus, Sr., Hous- ton. M.D., Memphis Hospital Medical Col- lege, Tenn., 1903; residency, Charity Hospital, Jackson, Sept. 1, 1918-Dec. 1, 1919; postgradu- ate work, Chicago EENT College, Illinois, 1920 and 1922; EENT Hospital, New Orleans, La., 1925 and 1927; member MSMA Fifty Year Club; Emeritus member MSMA and AMA: died Nov. 17, 1969, age 90.
Otken, Luther B., Sr., Greenwood. M.D., University of Texas Medical Branch, Galveston, 1917; interned Manhattan Maternity Hospital, New York City, N. Y., one year; died Nov. 25, 1969, age 80.
Raney, Daniel H., Mattson. M.D., Uni- versity of Texas Medical Branch, Galves- ton, 1917; interned St. Louis City Hospital, 3 months; scholarship Edinburgh, Scotland, 1919; member MSMA Fifty Year Club; Emeritus mem- ber MSMA and AMA; died Nov. 27, 1969, age 82.
No reports of election of new members in the association were reported to the Journal during December 1969.
JOURNAL MSMA
Book Reviews
Genetics and Counseling in Medical Practice. By Leonard E. Reisman, M.D. and Adam P. Matheny, Jr., Ph.D. 215 pages with illustrations. St. Louis: The C. V. Mosby Co., 1969. $12.75
This small volume provides a good overall view of genetic counseling aimed at the medical practitioner. It is easy to read, and well worth reading for anyone called on to provide counsel- ing for genetic disorders. Its greatest value is as a volume to read through for “the big picture” since it is not an exhaustive reference text. It nevertheless presents adequately the fundamen- tals of the major areas of medical genetics in- cluding probabilities, Mendelian principles, chro- mosome abnormalities and inborn errors.
Chapters on the general approach to genetic counseling, genetics and cancer, and mental re- tardation are particularly commendable. These chapters answer frequently-recurring questions directed by the medical practitioner to the genetic counselor. The authors have obviously drawn a great deal of the material from their own experi- ences in the sections on chromosome abnormali- ties and their clinical photographs are very good.
Diagrammatic illustrations explaining inherit- ance patterns are lacking, and the explanations in text, though adequate, may thus be hard to find for quick review by a busy practitioner. The authors have perpetuated the inadequate nationwide list of service facilities for genetic counseling which would be better omitted in fa- vor of a reference to the International Directory of Genetic Services edited by Bergsma and Lynch and published by the National Founda- tion.
John F. Jackson, M.D.
Symposium on Sports Medicine. By the Amer- ican Academy of Orthopaedic Surgeons. 210 pages with 199 illustrations. St. Louis: The C. V. Mosby Company, 1969. $15.00.
In 1962 the Executive Committee of the American Academy of Orthopaedic Surgeons established a Committee on Sports Medicine up-
on the recommendation of President-Elect Dr. Clinton Compere. This Committee was charged with many approaches to improving the medi- cal care, and particularly the orthopaedic care of American youth engaged in athletics. Dr. Don O’Donoghue was appointed chairman. A major mandate was to develop a sophisticated post- graduate course on sports medicine for ortho- paedic surgeons and other physicians with a spe- cial interest in the care of the athlete. At this postgraduate course approximately twenty very fine papers were presented and appropriately, the papers presented at this course have now been compiled as a birthday volume to Dr. O'Don- oghue.
The essayist of each of the individual papers is an expert in his field and all have a definite in- terest and insight into the problems of treating sports injuries. The articles are varied in their topics and include problems of evaluation of perspective athletes, as well as detailed reports of the effect of altitude on the athletes during the most recent Olympic games. All of the ex- tremities with reference to the most frequent in- juries are well covered and I feel that the six separate papers dealing with knee injuries are the best that 1 have seen.
This book would definitely be of benefit as a reference for any physician who is dealing with athletic injuries, whether he be an orthopaedic specialist or not. There are one hundred ninety- nine illustrations, which are all very well done and very clearly produced on paper.
I feel that the Committee on Sports Medicine of the American Academy of Orthopaedic Sur- geons should be commended on this publication and recommend it highly to any physician deal- ing with these problems.
H. Lowry Rush, Jr., M.D.
New Books Received
The Practice of Refraction. By Sir Stewart Duke-Elder, M.D., Ph.D., F.A.C.S. 321 pages with 244 illustrations. St. Louis: The C. V. Mosby Company, 1969. $11.75.
JANUARY 1 970
35
THE LITERATURE / Continued
Acute Renal Failure: Diagnosis and Manage- ment. By Robert G. Muehrcke, M.D., F.A.C.P. 263 pages with 126 illustrations. St. Louis: The C. V. Mosby Company, 1969. $19.75.
Health Education. By Bernice R. Moss, Ed.D., Warren H. Southworth, Dr. P.H., and John Les- ter Reichart, M.D. Washington, D. C.: National Education Association of the United States, 1969. Fifth Edition. $5.00.
Cardiac Arrest and Resuscitation. By Hugh E. Stephenson, Jr., M.D.. F.A.C.S. 500 pages with 223 illustrations. St. Louis: The C. V. Mos- by Company, 1969. $29.50.
Handbook of Ocular Therapeutics and Phar- macology. By Philip P. Ellis, M.D., and Donn L. Smith, M.D. and Ph.D. St. Louis: The C. V. Mosby Company, 1969. Third Edition. $10.75.
Fundamentals of Inhalation Therapy. By Don- ald F. Egan, M.D. 468 pages with 148 illustra- tions. St. Louis: The C. V. Mosby Company, 1969. $11.00.
Arrows of Mercy. By Philip Smith. 236 pages. Garden City N. Y. : Doubleday and Company, 1969. $5.95.
FDA Warns Against Bard Urethral Catheters
The Food and Drug Administration has issued a warning to all physicians and clinics against using 49 types of urethral catheter trays and kits produced by C. R. Bard, Inc., of Murray Hill. N. J.
All of these trays contain a packet of cleans- ing solution or “detergicide.” This detergi- cide,” also called “prep solution,” “cleansing so- lution,” or “antiseptic towlette,” has been found to contain bacteria of pseudomonas species, com- monly known as EO-1, a pathogenic organism which may produce severe genitourinary infec- tions.
C. R. Bard, Inc., undertook a voluntary recall in Sept, of the contaminated trays from its dis- tributors and from hospitals in the United States and Canada. FDA has determined that the re- call was not effective due in part to lack of co- operation by several large distributors who de- clined to participate.
FDA attempted to warn nursing homes and the medical profession of the dangers involved in the use of these trays by issuing a press re- lease in Oct.
Administration checks on dissemination of the warning revealed, however, that the majority of nursing and convalescent homes are still unaware of the recall or the health hazards of the cath- eter trays containing the contaminated detergi- cide. They are still in use in many institutions.
Recently a marked increase in severe genito- urinary infections associated with the use of the catheter trays containing the contaminated agent has been reported by hospital authorities.
Additional investigations by the FDA have also disclosed non-sterility of some of the lubri- cant jelly packs in the Bard trays. Both FDA and AMA are attempting to alert all physicians as- sociated with hospitals, urologic clinics, nursing and convalescent homes, to take immediate steps to check all stocks of sterile urethral catheter trays or kits from C. R. Bard, Inc. They should arrange for prompt return to the supplier of any existing stocks bearing any of the following re- order or item numbers:
7501, 7503, 7505, 7602, 7602P, 7604, 7610, 8145, 8214, 8216, 8218, 8220, 8300, 8364-16, 8364-18, 8365-16, 8365-18, 8400, 8401, 8464-16, 8464-18, 8464D-16, 8464D- 18, 8465-16. 8465-18, 8500, 8501, 8504-16, 8504-18, 8505-16, 8505-18, 8505A-16,
8505A-18, 8554, 8556, 8554-A, 8556-A, 8558, 8558-A, 8560, 8810, 8816, 8816-A, 8818, 8818-A, 8819, 4200, 4210, 8556-A,
8 5 60- A.
Frontiers of Medicine 1970 Scheduled
Registrations are being accepted for Frontiers of Medicine 1970 to be held in Lakeland, Flor- ida, Feb. 18 through 20. The meeting, sponsored by the Lakeland Graduate Medical Assembly, has been approved by the American Academy of General Practice for 14 hours elective credit.
A wide range of current medical topics is of- fered by this year’s Frontiers of Medicine pro- gram with an outstanding guest faculty from throughout the United States.
Co-sponsors of the Frontiers meeting — which last year was highlighted by Drs. Christiaan Barnard and Denton Cooley — are the medical staffs of Winter Haven Hospital and Bartow Memorial Hospital.
Registration fee is $100. For details, contact the Lakeland Graduate Medical Assembly, P. O. Box 23335, Lakeland, Florida 33830 (813/ 683-1636 or 683-2038).
36
JOURNAL MSMA
USM Student Health Services Offers Comprehensive Campus Care Program
One of the more important buildings at the University of Southern Mississippi in Hattiesburg is a modest two-story brick and tile structure on the main campus, nestled between a cluster of more imposing “cousins.”
The unit is the USM Infirmary, where despite a relatively limited floor space as compared to dormitory and classroom buildings, an astound- ing number of students trek annually through its doors.
Constructed in 1962, the unit replaced an outdated wooden building which had long since
Though small in size, in contrast to towering Pulley Hall at right , the University of Southern Mis- sissippi’s Health Services Clinic is a busy place, sometimes treating more than 6,000 out-patients a quarter. Only a portion of the two-story, 36-bed in- firmary is visible here. Dr. Thomas S. Martin, M.D. is Director of Health Services at USM.
seen its best days. The present infirmary has about 10,000 square feet of assignable area, 36 beds, and all of the necessary rooms for the ser- vices offered.
Dr. Thomas S. Martin is director of Student Health Services, and is now entering his fourth year with the school. Dr. Martin serves also as team physician, and as assistant professor of health and physical education, teaches some classes.
The staff at the infirmary consists of Dr. Martin and seven registered nurses, who rotate hours according to work load levels, so as to pro- vide 24-hour service. For a time a second phy- sician was available full-time. However Dr. Andin C. McLeod, Jr. has now left in order to obtain further specialized training.
The Student Health Services is supported by a health fee which is included in an incidental fee. Broadly it covers clinical and hospital ser- vices limited to cases of ordinary illness. The University does not assume responsibility in cases of extended illness or for treatment of chronic diseases. Cases requiring surgery are handled by a physician and hospital of the student’s choice.
After initial evaluation and possible treatment, the USM infirmary may make further disposi- tion of the patient, including continued treat- ment of minor illnesses either as a bed patient or as an ambulatory out-patient; referral to a local private physician or clinic for further diagnostic evaluation and treatment if the case is other than a routine minor illness; send the patient home to the care of his local physician if the condition war- rants, and especially if the expected duration of illness is lengthy; or requires hospitalization.
The School Health Service attempts to moni- tor and maintain surveillance over the student’s
JANUARY 1970
3 7
ORGANIZATION / Continued
general health, while he is away from home, and to offer liaison between his own family physi- cian, his parents, and/or his local physician.
Types of illness most frequently encountered, and their disposition, include:
The various types of tonsilopharyngitis are the most common illnesses seen. Where the duration is short, they are treated at the infirmary, but where a period of several weeks is anticipated, the cases are sent home for treatment by the family physician. Since it is important to identify and separate the cases of streptococcus bacterial sore throats so that they may be adequately treated in order to prevent rheumatic fever, a throat culture is taken in most cases, done by the State Board of Health at no charge.
Sprains and strains during intramural seasons and late afternoon activities produce many mus- culoskeletal injuries that are treated at the school. The nurses are well-trained in physical therapy measures. An ice machine and a whirlpool bath have proven invaluable. Other orthopedic prob- lems are generally referred to local orthopedic surgeons, of which there are now four in Hatties- burg.
Lacerations that occur on campus as a result of accidents, intramurals, or athletics are surgi- cally repaired in the clinic. Those resulting from automobile accidents and off-campus incidents are referred to the Forrest General Hospital emergency room. Though not deemed the respon- sibility of the school, the school physician is usually called upon by the hospital to care for these patients in the emergency room, the stu- dent bearing the cost.
Respiratory problems, most being of viral origin, are amenable to bed rest, anti-pyretics, and expectorants. More severe cases are often referred to the care of a local or home-town physician. X-rays are sometimes required, at the student’s expense, and are made at the Forrest General Hospital.
Bacterial pneumonia is generally not consid- ered a minor illness, but is sometimes treated on-campus, out of necessity or special conveni- ence to the patient.
Viral influenza does not lend itself to adequate treatment on the campus and victims are too ill to attend class. Because of this and the usual long duration, victims are sent home, as a rule, where there is a better chance for a more rapid recovery. In September, preventive “flu-shots” are offered — but the protection rate is only about
30 per cent and only a relatively few students and faculty avail themselves of the vaccine.
Gastrointestinal problems constitute the sec- ond most frequent complaint on campus, embrac- ing the syndrome of nausea, vomiting, and diar- rhea. Some of these illnesses are food-borne in origin, while most are the result of viral infection. Generally, an overnight stay in the clinic with proper supportive measures is adequate for re- covery. Acute abdominal emergencies are re- ferred elsewhere.
The clinic is equipped to handle acute asth- matic attacks, and other emergency situations due to allergies. Allergy injections, prescribed by private physicians, are administered by the nursing staff according to directions given by the student’s physician.
Emotional problems embracing acute hysteria, very mild depression, or anxiety cases fall in the category of minor illnesses, but more severe cases are referred elsewhere. Under the direction of a psychiatrist a student may be observed for several days in the clinic, when requested by his physician.
Genitourinary problems include cystitis, usual- ly treated at the clinic and followed up with re- ferral to specialists when required; and kidney trauma, with the clinic used in precautionary ob- servation, thus saving the student a large hos- pital bill.
The USM Clinic operates around the clock during each school quarter. Two scheduled clin- ics are held daily, one in the morning, the other in late afternoon. The late “sick call” draws the most patients. A daily clinic load for the physi- cian may consist of as few as 35 patients to a peak of 124.
The clinic operation provides most of the commonly used drugs to the student body free of charge. They often issue drugs such as antihista- mines, antibiotics, and antipyretics. Many pre- scriptions must still be written however and filled by area drug stores at student cost.
A universal problem for student health ser- vices is kept under moderate control at USM. Written excuses to class instructors for class ab- sences are not provided. At an institution of nearly 8,000 students, this has eliminated the unending lines of “written-excuse-seekers.” How- ever the student is encouraged to explain his problems to the instructors, and verification of clinic visits via telephone is always available if the instructor calls.
An indication of the patient load experienced over a period of time at USM is the fact that
38
JOURNAL MSMA
4.576 out-patients were treated during spring quarter as compared to 6.220 during winter quarter, 1969. During the same periods, 282 bed patients were provided for in spring quarter, and 387 during winter quarter.
Presently Southern is seeking another full time physician. “We hope to attract another man of Dr. Martin’s caliber,” Dean Peter E. Durkee comments. Any inquiries from interested physi- cians should be directed to Dr. Durkee, Dean of Student Affairs, Box 7, Southern Station, Hat- tiesburg. Miss. 39401.
MSU Mitchell Lectures Features Dr. Cooper
The C. B. Mitchell Lectures of Mississippi State University this year featured Dr. Louis Z. Cooper, one of the nation’s leading researchers on the Rubella or “German Measles” problem.
The second distinguished lecturer in the MSU series, Dr. Cooper is author of “Rubella: A Pre- ventable Cause of Birth Defects.” He received his M.D. degree from Yale University School of Med- icine and is currently affiliated with the New York University Medical Center and Bellevue Hospital.
While on campus Dr. Cooper spoke to pre- med students about challenges in the fields of career research, internal medicine, and pedi- atrics. On Mon., Dec. 8, he conducted an exten- sive testing of several thousand young women of child-bearing age to determine their suscepti- bility to Rubella.
Rubella, more commonly known as German or Three Day Measles, accounts for birth defects in hundreds of children each year. This year a “giant leap” in medicine was the production of an effective vaccine for Rubella along with a simple new technique for determining individual susceptibility (or immunity) to this previously wide-spread “childhood” disease.
The initial use of the vaccine is to go to all children who are primarily responsible for the epidemic spread of Rubella and the exposure to susceptible mothers-to-be. Prospective mothers should then be tested for immunity. Dr. Cooper says, “The concept is to vaccinate children to protect the mothers.”
The test for immunity consists of a drop of blood on a piece of filter paper. This properly
identified specimen processed in Dr. Cooper’s laboratory can determine if the patient has ever had Rubella. He estimates that there are 2,000,- 000 women of child-bearing age in this country who are susceptible.
The C. B. Mitchell Lectures initiated last year was tremendously successful with the two days and nights of appearances of the world known authority on the health hazards of tobacco, Dr. Alton Ochsner of New Orleans.
The C. B. Mitchell Pre-Med Fund was estab- lished in 1967 by Mississippi State University Medical Alumni and friends in recognition of the need for an enriched premedical curriculum at Mississippi State and in honor of the doctor who served MSU students for so many years as college physician.
The program was supported in part by the Merck Sharp and Dohme Post-Graduate Medi- cal Program and the Oktibbeha County March of Dimes.
Self-Employed M.D.’s Insured for Disability
Many self-employed physicians reached an im- portant social security landmark this October. With their earnings covered since 1965, they have now contributed to social security long enough to be insured for disability.
Social security disability benefits can be paid to an insured person under 65 who has a physi- cal or mental impairment so severe as to keep him from doing any substantial work for a year or longer. Payments begin after a waiting period of 6 full calendar months.
Benefits can be as much as $218 a month for a disabled person alone and up to $434.40 a month for a family. Self-employed physicians dis- abled in the immediate future, however, would probably not yet be eligible for these maximums since their earnings have been covered by social security for a relatively short time. Benefits are figured from a person’s average covered earnings over a period of years.
“This disability protection can be a valuable supplement to the physician’s private insurance,” said Bernard Popick. director of social security’s disability program. “It is part of the total social security package of protection — disability, re- tirement, survivors and health insurance — toward which the physician has been contributing.”
JANUARY 1970
39
ORGANIZATION / Continued
AMA’s Dr. McCleave Is MSMA and UMC Guest
As part of the continuing program of the MSMA Committee on Medicine and Religion, The Rev. Dr. Paul D. McCleave, director of the AMA department of medicine and religion, met with the state committee and appeared before the student assembly at the University Medical Center in late November.
In his remarks to the committee and the stu- dents, Dr. McCleave addressed himself to the care of the whole man and to problems in pa- tient care related both to physical aspects and to moral issues confronting both patients and phy- sicians.
Dr. John M. Alford, Jr. of Greenwood, chair- man, presided at the MSMA committee meeting. John Sanders, president of the junior class at UMC and chairman of the student assembly committee, served as host to Dr, McCleave. Also appearing on the program was Thad Waites of Waynesboro, student body president.
At the state association meeting, members of the UMC student government as well as Dr. Robert E. Carter, medical school dean and di- rector, were present as guests of the committee.
The Committee on Medicine and Religion is a constitutional body of the association whose members are Drs. Andrew K. Martinolich, Jr., of Bay St. Louis, F. C. Minkler, Jr., of Pasca- goula, S. Lamar Bailey of Kosciusko, Eugene M. Murphey, III, of Tupelo, Julian Wiener of Jack- son, and Dr. Alford, chairman.
Highlighting the MSMA Committee on Medicine and Religion meeting at which Dr. Paul McCleave, second from right , director of the AMA department of medicine and religion, appeared was a private luncheon at Primos' Northgate Restaurants. Discuss-
ing Dr. McCleave’s address are from left, Dr. Rob- ert Carter, UMC director and dean; Dr. John Alford, MSMA committee chairman; and John Sanders, chairman of the medical center student assembly committee.
40
JOURNAL MSMA
Regional Medical Expands Activities
Out of the planning and into the doing phase as of July 1, the Mississippi Regional Medical Program has mounted seven new projects and is set to expand two established activities with a $1,527,930 grant for 1969-70.
The award from the Division of Regional Med- ical Programs, Health Services and Mental Health Administration, DHEW, also covers cost of de- veloping additional projects to improve the qual- ity and availability of diagnosis and treatment of heart disease, cancer, stroke, and related dis- eases in Mississippi.
Says Dr. Guy Campbell, Mississippi coordi- nator, the seven new projects are pieces of an over-all plan to provide more health manpower, and improve the health service delivery system by Unking to available resources such as the State Board of Health, Office of Comprehensive Health Planning, and the University Medical Cen- ter.
Emphasis thus far is on continuing education and on clinic expansion, he says. New programs are:
Mississippi Postgraduate Institute in the Medi- cal Sciences, described elsewhere in this publi- cation, with the Mississippi State Medical As- sociation and University Medical Center as co- applicants.
Recruitment of Health Manpower in Mississip- pi— a Mississippi Hospital Association program to stimulate student interest in health careers and initiation of now nonexistent allied health train- ing programs.
Cardiovascular Clinics — The State Board of Health plan to strengthen its heart clinic network with the cooperation of local physicians, the Med- ical Center and the Mississippi Heart Association.
A System of Coronary Care Units in Mississip- pi— a University Medical Center project to estab- lish an exemplary coronary care unit in the teaching hospital as the first step in a system of regional centers which may monitor individual beds in smaller hospitals in the area.
Therapy Training and Consultation Program — The Medical Center’s project to begin correc- tion of deficiencies in personnel, facilities, and educational opportunities in radiation therapy so the service can be expanded and upgraded throughout the state. The first year’s budget will finance purchase of a linear accelerator.
Regional Comprehensive Neurology Clinics — The State Board of Health and Medical Center
joint plan for clinics in six cities to cover all neuro- logical disease with emphasis on stroke and with input from a primary and a rehabilitation team, and correlation with the heart clinics and the demonstration stroke unit at University.
Comprehensive Renal Disease Training Pro- gram— A Medical Center application to carry out training programs for physicians, nurses, and others who care for nephrology patients, includ- ing those on chronic dialysis.
Three-year funding was approved for five of the seven projects.
The grant also covers renovation funds for the pulmonary disease training program initiated as a feasibility study under earmarked money last March.
Support also continues for the four-bed Dem- onstration Stroke Unit which is to expand to six beds with the renovation of the vacated seventh floor nursing unit to be shared with the Clinical Research Center.
In approving the Mississippi program for op- erational activities, the national reviewing bodies noted the involvement of major health organiza- tions such as the Mississippi State Medical As- sociation in the planning process, the close tie- in with the Office of Comprehensive Health Plan- ning, and cordial relationship with adjoining re- gions. Mississippi’s avowed intent to do first what can be done with existing resources and the re- gion’s recognition of its health manpower as its key asset were seen as strengths in an early pro- gression from planning to activation.
Florida Hosts PG Education Program
The Department of Psychiatry of the Univer- sity of Florida College of Medicine and the north- east, central and southwest chapters of the Flor- ida Psychiatric Society will co-sponsor a pro- gram of continuing education in Gainesville, Florida on Feb. 10-11, 1970. The program will consist of lectures and workshops and will fea- ture Dr. Harold Rosen of Johns Hopkins Uni- versity of ‘‘Psychiatry and the Abortion Faws” and “Hypnosis in Psychiatry.” Dr. Samuel R. Warson of the department of psychiatry is di- rector of the workshop.
For programs and reservations requests should be directed to the Division of Postgraduate Edu- cation. J. Hillis Miller Health Center, Box 758, University of Florida, Gainesville, Florida 32601, Tel. 904-392-3143. A general announcement bro- chure will be distributed about Dec. 15.
JANUARY 1970
41
ORGANIZATION / Continued
UMC and MSBH Set Up Neurological Clinics
Two state agencies have pooled resources to put a new medical team in the field conducting clinics for victims of neurological diseases and related disorders.
Working together on the team are the State Board of Health, through its Division of General Health Services, and the University of Mississippi Medical Center in Jackson.
The effort is officially titled the Regional Com- prehensive Neurology Clinics project and is made possible under a grant from the Mississippi Re- gional Medical Program.
The team includes neurologists and resident physicians from the Medical Center, and a social worker, and it is supplemented at each clinic by State Board of Health nurses.
It conducts clinics on the third Monday and Tuesday of each month, spending one full day in each of six selected municipalities over a three-month period.
Two clinics are held in the State Board of Health county health department facilities in Meridian, Hattiesburg, Pascagoula, Gulfport, Cleveland and Indianola.
Dr. Frank M. Wiygul, Jr., director of the Division of General Health Services, State Board of Health, estimates that at least 1,000 patients will be seen through this new project over a one- year period.
He estimates 35 patients can be seen each clinic day, or 70 patients a month, for a total of 840 patients a year at the clinics, with another 160 referred from the clinics to the medical cen- ter.
Theoda Griffith and Terry Beck, working with Dr. Wiygul in the General Health Services Di- vision in setting up the clinic schedules, say the estimate may be on the conservative side.
“In addition to the medical team,” says Dr. Wiygul, “we have plans for a follow-up team, including an electroencephalogram technician, a physical therapist and a speech therapist.
“Patients with strokes and other neurological conditions which need more medical attention will be referred to University Hospital for admis- sion either to neurological service or to the stroke center.”
The aim of the project, says Dr. Wiygul, is to provide neurological consultation for patients out-
side of the central-Mississippi area which has comparatively easy access to facilities in Jack- son.
“We want to provide improved diagnostic ca- pability and over-all neurological care through laboratory procedures which are not routinely available elsewhere in the state,” Dr. Wiygul adds.
“The project also should develop referral re- sources for physicians in private practice, and it will develop community awareness of the special services needed by those with neurological dis- eases.
“We also will provide neurological consultant services to other health-related programs and orient existing health-resources agencies toward more comprehensive stroke evaluation and care.”
He said there is a possibility of expanding the project to the state’s northermost counties through a related project grant utilizing the University of Tennessee Medical School in Memphis.
The project now under way was approved for three years with the first year’s grant approxi- mately $60,000.
Dr. Wiygul pointed out that the current proj- ect is an outgrowth of an earlier epilepsy project which lasted five years with which he was associ- ated, and which was restricted to children.
Court Gives Upjohn Right to Argue
The U. S. Court of Appeals in Cincinnati. Ohio, has told The Upjohn Company that in December the court would hear oral argument on legal action by the company to prevent the Fed- eral Food and Drug Administration from en- forcing its order of Sept. 19, which would remove seven of the company’s combination antibiotic products from the market.
The court noted that the Food and Drug Ad- ministration had voluntarily agreed to suspend action against the products pending a decision by the court.
At the December hearing the court will hear argument on why the Sept. 19 order is illegal in seeking to remove the products from the market.
“The products like Panalba have been used widely and successfully for many years,” R. T. Parfet, Jr., president and general manager of Upjohn, said. “We believe the FDA is in er- ror in its attempt to remove them from the mar- ket and that the FDA action is unjustified.”
42
JOURNAL MSM A
Rubella Campaign Gets Good Results
State Board of Health officials report a satis- factory response thus far to a long-range Rubella immunization campaign concentrating on five- year-olds and six-year-olds.
“We don’t have enough vaccine to go into all 82 counties at once,” said Paul M. Turner, Jr., state coordinator for the Vaccination Assistance Program of the State Board of Health.
He said county-wide campaigns already have been carried out in Lamar and Perry counties, with some 70 per cent of the first-grade and second-grade children immunized in those two counties.
He said additional campaigns are already planned for Quitman, Benton, Claiborne, Copiah and Hinds counties and others will be announc- ing from day-to-day as “local health departments tool up to give the immunizations.”
“As the vaccine becomes more readily avail- able,” said Turner, “other health departments will make plans for clinics” in their local schools and Head Start centers. He added:
“State Board of Health technicians will go into these counties at the request of the local health departments, as each county takes on the responsibility of immunizing their children.”
Turner said the State Board of Health will soon release single-dose and ten-dose vials of Rubella vaccine to all 82 counties for routine use.
He pointed out at that time that the cam- paign is an “open-end” proposition, without dead- lines, since reaching all five-year-old and six- year-old children in the state will take time.
He also noted that reaching this age group is only the first phase of the total plan, which eventually will reach children up to age 1 1 .
“We’re talking about a ten-year span of age categories,” he said, “with more children coming on each year. That means at least 500.000 chil- dren. We estimate that the State Board of Health would immunize half, and private physicians half, so we’re talking about 250,000 children."
Dr. Blakey said the program might take three years and calls for a “massive effort” concen- trated both in time and in a sequence of priority age-groups.
He said Rubella “is one of the major known causes of congenital defects, such as heart disease, blindness and deafness,” and five-year-olds and six-year-olds are the most susceptible age groups.
Allergy Academy Announces PG Course
The American Academy of Allergy has an- nounced the program for a postgraduate course to be held Feb. 14-15, 1970, in the Jung Hotel, New Orleans, La.
Major topics to be covered include pulmonary diseases and asthma, developments in medicine relating to allergy, clinical immunology, and or- gan transplantation.
Featured speakers are Dr. Gustave A. Lau- renzi. St. Vincent Hospital of Worcester, Mass.; Professor Jack Pepys, Institute of Diseases of the Chest of London; Dr. Eugene Robbins, Uni- versity of Pittsburgh, Pa.; Dr. Charles R. Park of Vanderbilt University; Drs. Thomas C. Merigan and Keith B. Taylor of Stanford University.
Other lecturers include: Dr. Fred Rosen of Harvard; Ray D. Owen, Ph.D., California Insti- tute of Technology at Pasadena; R. E. Billing- ham, D.Sc., University of Pennsylvania at Phila- delphia; and Dr. David Hume, Medical Col- lege of Virginia at Richmond.
Miss. Med. Assistant Named AAMA Trustee
Mrs. Thomas D. Pace, Jr., Mississippi’s first certified medical assistant, was named trustee of the American Association of Medical Assistants at their 13th annual convention in Honolulu.
Mrs. Pace, who lives at 4545 Meadow Hill Drive, is administrative assistant to Dr. Myra Tyler at the University of Mississippi Medical Center.
She also was appointed as chairman of the AAMA junior college coordination committee, by the AAMA executive committee.
Mrs. Pace is president of the Mississippi Asso- ciation of Medical Assistants, vice president of the Jackson Symphony League and chairman of the Mississippi Art Association.
Featured speakers at the Honolulu convention included AMA President Gerald D. Dorman of New York and Dr. Christiaan N. Barnard of Johannesburg, Union of South Africa.
AAMA's 1970 convention will be held in Des Moines, Iowa.
JANUARY 1970
4 3
(
Medical Response to Camille Evaluated
An evaluation of the medical response to Hur- ricane Camille is under way following a disaster- evaluation planning conference in Gulfport.
Dr. Henry C. Huntley, Washington, D. C., chief of the Emergency Health Service division of H.E.W., flew to the coast to look at the disaster area and to attend the conference.
Afterwards, he said he will send interviewers from his office within the next week or so to pre- pare a comprehensive report on health services rendered in the wake of the hurricane.
“This disaster,” said Dr. Huntley, “affected more people to a greater extent — in a concen- trated population area — than any other in the United States in modern times.
“I’ve seen many disasters, but I’ve never seen the destruction and the number of people af- fected as I have here. I'm very impressed by the response of the community and the state.”
Dr. H. B. Cottrell, state health officer, Missis- sippi State Board of Health, cited “splendid co- operation between the medical community and the State Board of Health” in coping with the disaster.
He said follow-up work related to health ser- vices “will take weeks — maybe months,” espe- cially as regards environmental health — a re- sponsibility of the State Board of Health’s Di- vision of Sanitary Engineering.
Dr. Cottrell pointed to the need of continuous, long-range “collaboration and joint planning” by all health agencies and the related organizations at all levels involved in disaster work.
The Mississippi State Medical Association was represented at the high-level critique by Dr. C. D. Taylor, chief of the medical staff of Gulf- port Memorial Hospital, where the meeting was held.
Representing the Mississippi Hospital Associ- ation were Richard H. Malone, president of Hinds General Hospital in Jackson and presi- dent of the M.H.A., and Charles W. Flynn, Jack- son, M.H.A. executive director.
Also in attendance were administrative person- nel of coast-area hospitals, Keesler Air Force Base U.S.A.F. Medical Center, the Veterans Administration Center at Biloxi, and the State Board of Health.
A report on State Board of Health activities from the agency’s Gulf Coast Disaster Head-
quarters in the Harrison County Health De- partment in Gulfport was given by Dr. Frank J. Morgan, Jr., assistant state health officer.
A report on liaison between the State Board of Health and the coast-area medical commu- nity was presented by Dr. Edward C. Hamilton, vice chief of surgery, Gulfport Memorial Hos- pital.
Presiding at the two-hour meeting was Walter C. Hughes, Atlanta, program director, Division of Emergency Health Service, H.E.W. Hosting the meeting was Charles Wimberly, administra- tor, Gulfport Memorial Hospital.
Cardiovascular Specialists Schedule Session
The American College of Cardiology, the na- tional medical society for specialists and research scientists in cardiovascular diseases, will hold its 19th Annual Scientific Session Feb. 25-March 1, 1970 in New Orleans, La. All sessions will be held at The Rivergate Center.
Major scientific symposia will include such topics as surgery for complications of myocar- dial infarctions, cardiac valve substitution and pulmonary circulation. A new feature at the meeting this year will be a core curriculum in clinical cardiology and a self-assessment class room.
A special group of panel discussions, called Controversies in Cardiology, will feature discus- sions by authorities on opposing sides of current issues. Topics will include prevention of athero- sclerosis, homografts vs. prosthetic heart valves, alcoholic heart disease and surgery for coronary disease.
Doctors attending the meeting will also have a choice of 20 evening Fireside Conferences, 21 Luncheon panels, Clinical Conversations with Master Teachers, and a Round of Clinics and Demonstrations being arranged with hospitals and medical schools in the New Orleans area, ac- cording to B. L. Martz, M.D., Indianapolis, Ind., college president.
George E. Burch, M.D. and Allan M. Goldman, M.D., both of New Orleans, La., are general co-chairmen of the session. Dr. Burch is past president of the college and professor and chair- man of the department of medicine at Tulane University Medical School. Dr. Goldman is pro- fessor of clinical medicine at the medical school.
JANUARY 1970
45
for the problem drinker
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Pyridoxine HCI 5 mg
Niacinamide 100 mg
Calcium pantothenate 20 mg
Cyanocobalamin 5 meg
Folic acid 0.5 mg
Ascorbic acid 500 mg
Usual dosage is one tablet b.i.d.
Indications: Nutritional supplementation in conditions in which water-soluble vitamins are required prophylactically or therapeutically.
Warning: Not intended for treatment of pernicious anemia or other primary or secondary anemias. Neurologic involve- ment may develop or progress, despite temporary remission of anemia, in patients with pernicious anemia who receive more than 0.1 mg of folic acid per day and who are in- adequately treated with vitamin B]2.
Dosage: 1 or 2 tablets daily, as indicated by clinical need. Available: In bottles of 100.
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Israeli Develops Artificial Limb
An Israeli engineer has introduced a unique lightweight artificial arm having six movements which may be operated by electric impulses de- rived from muscle contraction.
Dr. Dino Bousso of the Technion-Israel In- stitute of Technology (Haifa, Israel), described the gas-powered limb as a “marked advance” in rehabilitation medicine at a press conference at the Institute of Rehabilitation Medicine of the New York University Medical Center.
“We are at the stage where we have an arm much lighter and versatile than anything avail- able, using electric control and pneumatic pow- er,” Dr. Bousso declared.
“I welcome this opportunity to bring the arm to the Institute of Rehabilitation Medicine for further evaluation.
“It is this type of international cooperation which furthers our field of expertise — and bene- fits mankind.”
Dr. Bousso, who developed the 13-ounce arm, said the limb’s “weight, simplicity and evenness of motion” are among its unique features. He is at the Institute on a grant and wants to evoke in- terest in the Technion-Bousso arm in America.
In describing the arm, which is at the labora- tory development stage, he said electric muscle impulses control the gas flow which pneumatical- ly powers its six movements — the only artificial limb to perform in such a versatile manner.
Here’s the way the Bousso arm works:
Electrodes, placed on muscles which can be voluntarily tensed, pick up minute electrical im- pulses generated in the muscles whenever the pa- tient’s brain wills them to contract.
These electrical impulses, when amplified, op- erate a pneumatic solenoid valve that regulates gas flow into the actuators.
The limb is one-third the weight of other ar- tificial limbs enabling children to use it, accord- ing to Dr. Bousso. It is also structured so a child can recharge the gas container alone.
The arm is comprised of light aluminum al- loys and high-strength plastic material — mainly nylon.
Features of the Bousso limb include:
— close simulation of normal arm movements through use of a special rotary actuator.
— extremely low weight of the limb which uses gas as its energy source, and doubling of control signals which can be obtained per muscle.
— simplicity and compactness of the electronic
circuit which can be fitted into the arm itself, and ease in operating the limb.
Dr. Bousso’s research was supported by a $40,000 grant from two private British charity funds — the Lady Hoare Thalidomide Appeal and the Goudie Trust — designed to help the nearly 5,000 European children afflicted by the drug while their mothers were pregnant.
Dr. Bousso began his research by concentrat- ing on developing a rotary actuator which trans- forms energy directly into rotary motion.
He was able to produce a new type rotary pouch actuator with high efficiency, low volume and weight, suited to perform more movements and carry higher loads than the piston actuators used up to now.
The result was an artificial limb with six differ- ent movements. Gripping elements of the limbs are equipped with optical gauges which indicate the amount of force exerted.
The limbs are harnessed to the body by a cor- set molded to the contours of the user. Limb components can be extended as the child grows. Working pressure of the gas also can be acceler- ated to increase its power.
Dr. Dino Bousso of the Technion-Israel Institute of Technology (Haifa, Israel), displays unique gas- powered 13 oz. arm — said to be lightest ever con- ceived. The Technion-Bousso arm, comprised of aluminum and plastic — mainly nylon, has six move- ments, also a first, which Dr. Bousso described as a “marked advance” in rehabilitation medicine.
JANUARY 1970
47
Doctor, after all we’ve been through together. . .
abscess
acne
amebiasis
anthrax
bacillary dysentery bartonellosis bronchitis bronchopulmonary infection
brucellosis chancroid diphtheria endocarditis genitourinary infections gonorrhea granuloma inguinale listeriosis lymphogranuloma
mixed bacterial infection osteomyelitis otitis pertussis pharyngitis pneumonia psittacosis pyelonephritis
Rocky Mountain spotted fever scarlet fever septicemias sinusitis
soft tissue infection tonsillitis tularemia typhus fever urethritis
. . .don’t you think it’s time we were on a first-name basis?
caii me^AchroV
55
Every pharmacist knows ACHRO® V stands for ACHROMYCIN® V
Contraindications: Hypersensitivity to tetracycline.
Warning: In renal impairment, since liver toxicity is possible, lower doses are indicated; during prolonged therapy consider serum level determinations. Photodynamic reaction to sunlight may occur in hypersensitive persons. Photosensitive individuals should avoid exposure; discontinue treatment if skin discomfort occurs.
Precautions: Nonsusceptible organisms
may overgrow; treat superinfection appropriately. Tetracycline may form a stable calcium complex in bone-forming tissue and may cause dental staining during tooth development (last half of pregnancy, neonatal period, infancy, early childhood).
Adverse Reactions: Gastrointestinal— anorexia, nausea, vomiting, diarrhea, stomatitis, glossitis, enterocolitis, pruritus ani. Skin— maculopapular and erythematous rashes; exfoliative
dermatitis; photosensitivity; onycholysis, nail discoloration. Kidney -dose-related rise in BUN. Hypersensitivity reactions— urticaria, angioneurotic edema, anaphylaxis. Intracranial— bulging fontanels in young infants. Teeth— yellow-brown staining; enamel hypoplasia. Blood— anemia, thror bocytopenic purpura, neutropenia, eosim philia. Liver— cholestasis at high dosage. Upon adverse reaction, stop medication and treat appropriately.
AchromyciifV
Tetracycline
UAB Uses MIRU Computer
A great deal of human brainpower went into the planning of the University of Alabama Med- ical Center’s Myocardial Infarction Research Unit, but when the unit begins operation next month, an electronic brain takes over some of the actual work — a brain which can calculate the interac- tion of a vast number of details and come up with a split-second response.
The computer which backs up the operation of MIRU was installed at a cost of $309,000 and is programmed solely for the University Hospital unit, relieving paramedical personnel of many time-consuming duties and providing a constant flow of information from patient to memory bank.
Not only will the MIRU computer monitor bodily functions and provide, with the touch of a button, almost any kind of information re- quired by doctors, nurses, or technicians, but it will constantly increase its store of information about myocardial infarction, enabling doctors to expand their knowledge of how to combat the disease.
The computer is not new — there are other IBM 1800’s in existence. But what is being done with it is new and innovative. The computer is designed to monitor several patients at one time, instantly providing vital information to those in charge, whenever they need it.
Previous monitoring systems have been less flexible than that used by the UAB computer. There were limitations on which types of re- search programs could be incorporated without interfering with the patient monitoring activities.
The MIRU system is continuously collecting information about the patients in the unit to per- mit intensive supervision, with alarms for the staff when significant changes occur. The collect- ed information is saved on magnetic tape to pro- vide the tremendous amounts of data needed for later research use.
In the past, the different functions of monitor- ing systems had to be separately and indepen- dently constructed. The new UAB MIRU system retains common elements which are always avail- able to be called into action when needed, pro- viding the flexibility which has previously been sacrificed in order to gain high computer perform- ance.
The computer will be programmed to make life-and-death decisions only when criteria for the decisions can be stated in quantitative terms by the doctor. It will always operate under a phy-
sician’s control, whether he is physically present or not. The machine cannot replace a doctor’s care, but it will supplement and assist him in ways a human brain is neither rapid enough nor vast enough to do.
According to MIRU senior systems analyst Steven E. Wixson, “The health sciences are now entering the age of the computer, an age when stopping a computer’s operation, even for a mo- ment, may represent a hazard to the patient.’’
The MIRU installation is designed to continue functioning even when some of the components fail electronically. Parts of the system are used primarily for research by the UA School of Medi- cine faculty — other equipment is for research as well as for continuous monitoring and evalua- tion of bodily functions in patients.
Some units of the computer have duplicate parts which are interchangeable, allowing the re- search section to assume those functions of the monitoring section in case of sudden failure in operation. Such duplication has been the rule wherever the research needs have justified ex- penditure for equipment.
Scientists anticipate a day when computer-col- lected information will enable the physician to perform his duties in regulating patient care with more efficiency and accuracy than is now pos- sible.
Answers to Cancer Quiz
From Cancer Facts and Figures, The Ameri- can Cancer Society:
1. (b) 15%. The current figure is approximate-
ly 16% of deaths in the U.S.A. are can- cer deaths.
2. (b) Slightly over 300,000 annual deaths.
3. (b) Slightly over 1 death every two minutes.
4. (c) 55% men/45% women.
5. (c) Lung cancer, 1st approximately 52,000,
and (d) rectal-colon, 2nd approximately
44.000.
6. (a) Lung cancer, 1st approximately 44,000,
and (b) rectal-colon 2nd, approximately
21.000.
7. (b) Breast cancer, 1st approximately 27,-
000 and (d) rectal-colon cancer, ap- proximately 23,000.
8. (d) Skin cancer.
9. (c) A little over 3,000.
10. (b) Approximately 21 patients in a local community of 5.000 will be under can- cer care. Of these, 7 will die. Of the 14 new cases diagnosed during the year, 5 will be cured.
JANUARY 1970
49
ORGANIZATION / Continued
Gastroenterology Course Planned for Internists
The American College of Physicians (ACP) will hold a five-day postgraduate course on “Function and Dysfunction of Gastrointestinal Tract” Jan. 2-6, 1970 in Bal Harbour, Fla.
The course, being held in cooperation with the University of Miami School of Medicine, will be held at the Americana Hotel. It is one of 25 postgraduate courses the ACP is conducting throughout the United States and Canada during the 1969-70 academic year to help specialists in internal medicine keep abreast of new knowledge and techniques in the diagnosis and treatment of diseases.
The Bal Harbour course will concentrate on recent advances in gastroenterology that relate to normal and abnormal function, particularly in regard to gastrointestinal secretions and absorptions. Panel discussions will be concerned with diagnostic and therapeutic controversies and will be held daily. Self-assessment examinations will be available for those internists who wish to take them.
Martin H. Kaiser, M.D., Miami, Fla. professor of medicine and physiology (gastroenterology) at the University of Miami School of Medicine, is course director. Co-director is Arvey I. Rogers, M.D., Miami, assistant professor of medicine at the medical school and chief of the gastroenterol- ogy section at the Miami Veterans Administra- tion Hosptial. The faculty for the course will be drawn from the medical school, with guest lec- turers from the Albert Einstein School of Medi- cine, the Mayo Clinic, the University of Illinois, Boston University and other institutions.
Tri- State Thoracic Society Meets
Chest specialists from Mississippi, Alabama, and Louisiana will convene in Biloxi at the Buena Vista Hotel on Friday and Saturday, Jan. 10 and 11, for the 14th Annual Tri-State Tho- racic Society Consecutive Case Conference, ac- cording to an announcement by Dr. Wilfred Cole, president, Mississippi Thoracic Society.
This special scientific meeting is co-sponsored by the thoracic societies and tuberculosis and respiratory disease associations of Mississippi, Alabama, and Louisiana.
Members of the Mississippi Thoracic Society featured on the program during the two day ses- sion include Drs. H. Richard Johnson, Rush Net- terville, Charles Parkman, Bob Robertson, Walter Treadwell, and Myra Tyler, all of Jackson. Dr. G. Boyd Shaw, Jackson, will serve as moderator for one of the three scientific sessions.
Guest discussants invited for the two day con- ference will be: Dr. Vernon N. Houk, Atlanta; Dr. Robert R. Shaw, Dallas; and Dr. Louis Raider, Mobile.
Other program participants include: Dr. Thom- as H. Allen, Birmingham; Dr. Jack Green, Mo- bile; Dr. Robert L. Dillenkoffer, New Orleans; and Dr. Dean B. Ellithorpe, New Orleans.
Topics for discussion include segmental resec- tions, pulmonary angiograms, chest trauma, and middle lobe syndrome.
Further information and advance reservations can be made by contacting Mississippi Thoracic Society, P. O. Box 9865, Northside Station, Jackson, Miss. 39206.
UMC Announces New Appointments
Seven new appointments went into effect at the University of Mississippi School of Medicine in December. Two pathologists at the Jackson Veteran’s Administration Hospital have received faculty appointments as assistant professors of pathology. Dr. Lloyd L. Barta and Dr. Ezatollah Foroughi.
Dr. Barta, who received his M.D. degree from the University of Nebraska School of Medicine, was an intern at McCook Memorial Hospital and a resident at New Orleans Charity Hospital. He is acting chief of laboratory service at the V.A. Hospital.
Dr. Foroughi, holding an M.D. degree from Teheran University Medical School in Iran, served his internship at Mercy-Timken-Mercy Hospital and residencies at Kansas University Medical Center, St. Luke’s Hospital and New England Deaconess Hospital.
Instructors joining the faculty are Miss Vicki G. Hendershot, instructor in surgery (otolaryn- gology); Dr. Krishna Potnis, instructor in ob- stetrics-gynecology; and Edward Eugene Thomp- son, clinical instructor in surgery (otolaryngol- ogy).
Miss Constance Juzwiak and Miss Carol June Smith are both new associates in obstetrics- gynecology, in connection with the nurse-mid- wifery program.
5 0
JOURNAL MSMA
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Index to Advertisers
Arch Laboratories
51 William S. Merrell Company
44
Breon Laboratories 10A, 10B, 10C, 10D National Drug Company second cover, 36A, 36B
Burroughs-Wellcome 24A New Orleans Graduate Assembly 11
Campbell Soup Company 20A
Geigy Pharmaceuticals 24B, 24C, 24D
Glenbrook Laboratories 8
Highland Hospital 10
Hillcrest Hospital 29
Hynson, Westcott and Dunning 3
Kay Surgical 51
Lederle Laboratories 4, 31, 48
Eli Lilly front cover, 14
Parke Davis 40C, 40D
Poythress 40B
Robins Company 20D, 33
Roche Laboratories 12, 46, fourth cover
Sandoz 40A
G. D. Searle Company 20B, 20C
Stuart Company 34
Wyeth Laboratories 6, 7
Thomas Yates and Company third cover
California's 1970 senate race is shaping up with all sorts of health care policy overtones. State GOP is said to be easing out conservative Sen. George Murphy who has throat tumor and can't cai paign effectively. Favored to run is HEW Secretary Robert Finch instead, and Democrats will probably nominate popular president oj San Francisco State College, Dr . S . I . Hayakawa , who, if elected, would be third Japanese- American in U.S. Senate.
National Medical Association, predominately black professional society, says that only 6,000 or 3 per cent of nation's M.D. 's are Negro and that two medical schools, Howard and Meharry, have gradt ated 83 per cent of them. More blacks are in private practice ths whites (73 vs. 65 per cent), and black physicians have higher per- centage of GP's. Three per cent of Mississippi's M.D. 's are black
Alabama's Medicaid program, beginning Jan. 1, will pay physicians their usual and customary fees, while Mississippi's are held to 50th to 60th percentiles. Alabama program consists of insurance policies for physicians' services administered by Equitable Life. Blue Cross is fiscal intermediary for hospital services, and a ban will handle drug program administration.
The much-shaken Food and Drug Administration has its third commis- sioner in 18 months. Dr. tiharles 6. Edwards, former high AMA staf executive, is new commissioner, succeeding far. Herbert L. Ley. Jr. who lasted a year and a half after replacing the controversial Dr. James Goddard. FDA has been shoved down to low level in HEW Hierarchy by Secretary Finch who is chief shaker-upper.
Nobel laureate Dr. Linus Pauling commended oranges as a therapeuti specific to the 2nd International Congress of Social Psychiatry. ] said that vitamin C gives increased vigor, protection against viru and helps healing wounds, in addition to being a probable specific in schizophrenia. He reported low levels of ascorbic acid in schizophrenics where investigators discovered only one- third as much as is found in individuals of normal mental health.
Volume XI Number 2
February 1970
• EDITOR
William M. Dabney, M.D.
• ASSOCIATE EDITORS George H. Martin, M.D. Thomas W. Wesson, M.D.
• MANAGING EDITOR Rowland B. Kennedy
• EDITORIAL CONSULTANT Betty M. Sadler
• EDITORIAL ASSISTANT Nola Gibson
• PUBLICATIONS COMMITTEE Lawrence W. Long, M.D.
Chairman
Frank L. Butler, Jr., M.D. William E. Lotterhos, M.D. and the editors
• THE ASSOCIATION James L. Royals, M.D.
President
Paul B. Brumby, M.D.
President-elect Walter H. Simmons, M.D.
Secretary-T reasurer William E. Lotterhos, M.D. Speaker
John B. Howell, Jr., M.D.
Vice Speaker Rowland B. Kennedy Executive Secretary H. C. Harrell Executive Assistant
The Journal of the Mississippi State Medical Association is owned and pub- lished by the Mississippi State Medical Association, founded 1856. Editorial, ex- ecutive, and business offices, 735 Riverside Drive, Jackson, Mississippi 39216; office of publication, 1201-5 Bluff Street, Fulton, Missouri 65251. Subscription rate, $7.50 per annum; $1 per copy, as available. Ad- vertising rates furnished on request. Second-class postage paid at the post office at Fulton, Missouri.
CONTENTS
ORIGINAL papers
Prevention of Maternal Rh Sensitization; Anti-Rh
Immune Globulin 53 William B. Wilson, M.D.
Direct-Current Cardioversion With Diazepam as Sedative
Agent 57 William H. Rosenblatt, M.D., and Dexter C. Nettles, M.D.
SPECIAL ARTICLES
Guidelines to Increase Efficiency of the Hospital
Emergency Department 61 John T. Milam, M.D.
Radiologic Seminar XCII:
Subclavian Steal Syndrome 66 T. S. McCay, M.D.
EDITORIALS
Medicredit: Delivery System in AMA’s Image
Additives: HEW, FDA, MSG, LD50
Data Show Appendectomy Is Safe
The Agony and the Ecstasy of Taxes
Work and Play OTV Can Be Dangerous
69 Done With Taxes 71 Tenuous Conclusions
71 Figures in Our Favor
72 Watch the Small Print
73 Snowmobile Menace
THIS MONTH
The President Speaking 68 Best Part of the Job
Medical Organization 79 Formal Opening of New
Headquarters Addition
Copyright 1970, Mississippi State Medical Association
for the debilitated geriatric patient
TABLETS
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Each Berocca Tablet contains:
Thiamine mononitrate 15 mg
Riboflavin 15 mg
Pyridoxine HCI 5 mg
Niacinamide 100 mg
Calcium pantothenate 20 mg
Cyanocobalamin 5 meg
Folic acid 0.5 mg
Ascorbic acid 500 mg
Usual dosage is one tablet b.i.d.
Indications: Nutritional supplementation in conditions in which water-soluble vitamins are required prophylactically or therapeutically.
Warning: Not intended for treatment of pernicious anemia or other primary or secondary anemias. Neurologic involve- ment may develop or progress, despite temporary remission of anemia, in patients with pernicious anemia who receive more than 0.1 mg of folic acid per day and who are in- adequately treated with vitamin Bi2-
Dosage: 1 or 2 tablets daily, as indicated by clinical need. Available: In bottles of 100.
Roche
LABORATORIES
Division of Hoffmann-La Roche Inc. Nutley. New Jersey 07110
MISSISSIPPI STATE MEDICAL ASSOCIATION
7
AMA Names Private Practice Committee
Dr. W. B. Hildebrand of Menasha, Wis., has been elected chairman of the American Medical Association’s Committee on Private Practice dur- ing its organizational meeting at Chicago.
The committee, a component of AMA’s Coun- cil on Medical Service, was created by the House of Delegates at its recent clinical convention in Denver.
A former president of the American Academy of General Practice, Dr. Hildebrand has been a member of the Council since 1968. He is also an AMA Commissioner to the joint Commis- sion on the Accreditation of Hospitals. From 1960-64 Dr. Hildebrand served as a member of AMA’s Commission on the Cost of Medical Care.
Vice-chairman of the new Committee is Dr. Robert E. Tschantz, of Canton, Ohio.
Other members are: Drs. C. Willard Camalier,
Jr., Washington, D. C.; Burns A. Dobbins, Fort Lauderdale, Fla.; Frank H. Green, Rushville, Ind.; Warren A. Lapp, Brooklyn, N. Y.; Clinton S. McGill. Portland, Ore.
Also, Drs. John G. Morrison, San Leandro, Calif.; Tom E. Nesbitt, Nashville, Tenn.; Andrew L. Thomas, Chicago; George W. Wood, III, Brewer, Maine.
The committee was the final outgrowth of a planning and development report, and the initial recommendation was for a Council on Private Practice. The House of Delegates, however, de- clined to create a new council and accorded the group committee status.
Historically, the role of the Council on Medical Service has been closely related to the private practice of medicine, and the delegates placed the committee under this parent body.
It is expected that the new committee will re- port to the House of Delegates through the Coun- cil on Medical Service at the Chicago annual con- vention next June.
LAKELAND NURSING CENTER
“MISSISSIPPI'S NEWEST”
A 105 BED EXTENDED CARE FACILITY, MEDICARE APPROVED, EQUIPPED FOR REHABILI- TATION OF THE SICK WITH PHYSICAL THERAPY, INHALATION THERAPY, SPEECH THER- APY AND OCCUPATIONAL THERAPY. OPEN STAFF. FULL TIME MEDICAL DIRECTOR AND EMERGENCY MEDICAL CALL COVERAGE.
For Admission Call:
WILLIAM F. KLIESCH, M.D.
MEDICAL DIRECTOR AND ADMINISTRATOR 3680 LAKELAND LANE JACKSON, MISSISSIPPI DIAL 982-5505
8
THE JOURNAL FOR FEBRUARY 1970
in cardiac edema
gets the water out
spares the potassium
Before prescribing, see complete prescribing in- formation in SK&F literature or PDR.
Contraindications: Pre-existing elevated
serum potassium. Hypersensitivity to either com- ponent. Continued use in progressive renal or hepatic dysfunction or developing hyperkalemia.
Warnings: Do not use dietary potassium sup-
plements or potassium salts unless hypokalemia develops or dietary potassium intake is mark- edly impaired. Enteric-coated potassium salts may cause small bowel stenosis with or without ulceration. Hyperkalemia (>5.4 mEq/L) has been reported, in 4% of patients under 60 years, in 12% of patients over 60 years, and in less than 8% of patients overall. Rarely, cases have been as- sociated with cardiac irregularities. Accordingly, check serum potassium and BUN during therapy, particularly in patients with suspected or con- firmed renal or hepatic insufficiency (e.g., cer- tain elderly or diabetics). If hyperkalemia de- velops, substitute a thiazide alone. If spironolac- tone is used concomitantly with ‘Dyazide’, check serum potassium frequently — their combined use can cause potassium retention and sometimes hyperkalemia. Two deaths have been reported in patients on such combined therapy (in one, recommended dosage was exceeded; in the other, serum electrolytes were not properly monitored). Observe regularly for possible blood dyscrasias, liver damage or other idiosyncratic reactions. Blood dyscrasias have been reported in patients receiving Dyrenium (triamterene, sk&f). Rarely, leukopenia, thrombocytopenia, agranulocytosis, and aplastic anemia have been reported with the thiazides. Watch for signs of impending coma in acutely ill cirrhotics. Thiazides are reported to
cross the placental barrier and appear in breast milk; thus adverse reactions which have occurred in adults may occur in the fetus or newborn infant. Rarely, thrombocytopenia or pancreatitis has de- veloped in newborn infants whose mothers had received thiazides during pregnancy. When used during pregnancy or in women who might bear children, weigh potential benefits against possible hazards to fetus.
Precautions: Do periodic serum electrolyte de- terminations. Do periodic blood studies in cir- rhotics with splenomegaly. Antihypertensive ef- fects may be enhanced in postsympathectomy pa- tients. The following may occur: hyperuricemia and gout, reversible nitrogen retention, decreasing alkali reserve with possible metabolic acidosis, hyperglycemia and glycosuria (diabetic insulin requirements may be altered), digitalis intoxica- tion (in hypokalemia). Use cautiously in surgical patients. Adjust dose of antihypertensive agents given concomitantly.
Adverse Reactions: Muscle cramps, weak- ness, dizziness, headache, dry mouth; anaphy- laxis; rash, urticaria, photosensitivity, purpura, other dermatological conditions; nausea and vom- iting (may indicate electrolyte imbalance), diar- rhea, constipation, other gastrointestinal distur- bances. Rarely, necrotizing vasculitis, altered car- bohydrate metabolism, hyperbilirubinemia, par- esthesias, icterus, pancreatitis, and xanthopsia have occurred with thiazides alone.
Supplied: Bottles of 100 capsules.
SK
&F
Smith Kline & French Laboratories
February 1970
)ar Doctor:
i 11 to permit physicians to organize professional corporations for ' x benefits has been introduced in 1970 session of the Legislature, onsored by state medical association, measure is House Bill 48 by p. Fred Lotterhos of Hinds. Parallel measure has been intro- ced by Rep. George Rogers of Warren to include attorneys.
Bid by Treasury Department to hobble professional cor- porations in Tax Reform Act of 1969 was beaten by AMA.
So both Congress and courts have recognized validity of professional corporations. Physicians favoring bill should talk it up to legislators.
arp increase in Medicare Part 1-B premium to $3.30 from $4 is fective July 1, nearly doubling original figure of $3 in I96I3. t mentioned, however, in howls over physicians’ fees is that ly 26 cents of increase is earmarked for future rises in medi-
I care charges. HEW Secretary Finch blames big increase on rmer HEW boss Wilbur Cohen's failing to up price two years ago.
Propraetors are working overtime in Jackson and Washington to ke cultism legal in Mississippi and profitable under Medicare.
II to license chiropractors may be introduced at any time in gislature. In Congress, 87 representatives from 30 states are -sponsoring bills to pay for cult services under Medicare, but
Mississippi Congressmen are among them.
.surance companies and Blue plans have year of grace before having 1 make reports to Internal Revenue Service of payments to M.D. 's.
IS backed down and revised beginning date to Jan. 1, 1971, after dch carriers and Blues must report payments of $600 or more in iy year to physicians. Rule has long been in effect for CHAMPUS, idicare, and Medicaid.
> smoking is the word in every hospital and medical facility of S. Air Force, both for patients and medical personnel. Air Lrgeon General, with full backing of Pentagon, prohibits patients' loking during hospitalization and bans sale of all tobacco pro- mts in vending machines and hospital base exchanges.
Rowland B. Kennedy Executive Secretary
10
THE JOURNAL FOR FEBRUARY 1970
Today’s Health Explores Sensitivity Training
“Sensitivity Training: Fad, Fraud or New Fron- tier” is the title of a major article in the Jan., 1970 issue of Today’s Health magazine, the AMA publication edited primarily for non-professional readers.
However, sensitivity training is so new and experimental even physicians are often unfamiliar with its concepts, techniques and goals; yet an increasing number of patients are asking for pro- fessional evaluation.
This article, by Ted J. Rakstis, supplies many of the answers for physicians to questions they may be asked — before they are asked.
Sensitivity training comes with many other names: encounter groups, personal growth labs, T-groups (“T” for training), awareness experi- ence confrontation groups, training laboratories, organizational development and, collectively, the human potential movement. Whatever the groups are called, the phenomenon is attracting hundreds of thousands of Americans of all ages to programs run by persons who may be either skilled pro- fessionals or rank amateurs.
The tangle of sensitivity training nomenclature | suggests that not even the experts can clearly de- II line it, the author maintains. It incorporates ele- M ments of psychiatry, sociology, philosophy, educa- tion, religion and community organization. Its practitioners number people from these and other ¥ fields; but depending upon his professional back- ground and personal bias, each person who con- ducts a sensitivity group has a different focus.
Most sensitivity sessions share several com- f mon attributes, however. The programs are de- signed to place people in a group situation. Through a mixture of physical contact games ;s and no-holds-barred discussions about each oth- ; er’s strengths and failures, each group member hopefully feels less constricted. He will become more open, readily able to understand himself and others.
The Today’s Health article analyzes the claims of both proponents and opponents, as well as the questions of the skeptics.
The author points out the sensitivity training boom has come so quickly and assumes so many forms that most of the experts have been caught off guard. Neither the American Psychological Association nor the American Psychiatric Asso- ciation has an official position.
xJjiff Q/iest
HOSPITAL
(Formerly Hill Crest Sanitarium)
7000 5TH AVENUE SOUTH Box 2896, Woodlawn Station Birmingham, Alabama 35212
Phone: 205-836-7201
A patient centered independent hospital for intensive treatment of nervous disorders . . .
Hill Crest Hospital was estab- lished in 1925 as Hill Crest Sanitarium to provide private psychiatric treatment of ner- vous or mental disorders. Indi- vidual patient care has been the theme during its 44 years of service.
Both male and female pa-
tients are accepted and depart- mentalized care is provided ac- cording to sex and the degree of illness.
In addition to the psychiatric staff, consultants are available in all medical specialities.
MEDICAL DIRECTOR:
James A. Becton, M.D., F.A.P.A.
CLINICAL DIRECTORS:
James K. Ward, M.D., F.A.P.A. Hardin M. Ritchey, M.D., F.A.P.A.
HILL CREST is a member of:
AMERICAN HOSPITAL ASSOCIATION . . . . . . NATIONAL ASSOCIATION OF PRI- VATE PSYCHIATRIC HOSPITALS . . . ALABAMA HOSPITAL ASSOCIATION . . . BIRMINGHAM REGIONAL HOSPITAL COUNCIL.
Hill Crest is fully accredited by the Joint Commission on Accreditation of Hospitals and is also approved lor Medicare pa- tients.
SfcfiM Cues t
HOSPITAL
BIRMINGHAM, ALABAMA
*
\
i
-stees Accredit Jackson - Eighteen schools of nursing in Mis- j Nursing Schools sissippi have been accredited for 1970 by the
Board of Trustees of Institutions of Higher -rning. Program includes three hospital diploma schools, four : calaureate sources, and 11 associate degree programs. UMC, iversity of Southern Mississippi, Mississippi College, and Wil- _m Carey College offer B.3. in nursing.
, . Abortion Law Washington - The District of Columbia abortion [Held Invalid statute was held invalid in federal court to
the extent that it prohibits procedure unless cess ary for preservation of the mother's life or health." The :.rt ruled, however, that abortion is unlawful unless performed ,a competent medical practitioner. Basis of edict is denial of |i process and right of privacy in "removal of unwanted child. "
[licaid Will Pay Memphis - Mayor Henry Loeb says that Missis- Memphis Care sippi will pay Memphis hospitals from Medicaid
funds for care of its indigents admitted there, "eement was reached recently after Memphis mayor threatened to )se hospitals to Mississippi welfare patients unless state paid "e than $12.50 per day under old program. Loeb claims that per 5m costs in Memphis institutions are $65.
iiatrists Nixed Youngstown, 0. - An appellate court sustained
Ohio Hospitals an Ohio hospital in denying staff privileges
to podiatrists. Suit was filed by applicant ter refusal of membership and his request for surgical privi- g;es. Hospital claimed to have acted on basis of statutory nitations on podiatrists' practice privileges. Although not on ssissippi hospital staffs, podiatrists perform major surgery offices.
PA Backs Eight Washington - The Aircraft Owners and Pilots or Drink Rule Association, a 150,000-member group repre-
senting private aviation, has recommended option of federal regulation prohibiting anyone from flying an rplane within eight hours of consuming alcoholic beverages or king drugs which would impair faculties. While airlines have ag had a 24-hour nondrinking rule , there is none for private lots. Some accidents have been attributed to alcohol.
THE JOURNAL FOR FEBRUARY 1970
1 4
Lilly Develops Topical Steroid
Uniform topical steroidal medication of the skin is available for the first time in a transparent plastic occlusive tape introduced by Eli Lilly and Company. The new drug formulation — Cor- dran® Tape (flurandrenolone tape, Lilly) — is practically invisible when in place and can be masked by applying makeup over it.
Because flurandrenolone is evenly distributed in the tape’s adhesive, the same dose is applied to every square centimeter of skin treated.
Cordran Tape is indicated in the treatment of the following conditions: atopic dermatitis, con- tact dermatitis, eczema of hands and feet, lichen planus, lichen simplex chronicus, neurodermatitis, nummular eczema, psoriasis, seborrheic derma- titis, and stasis dermatitis. It is not satisfactory therapy for alopecia areata.
Investigators who evaluated the effectiveness of Cordran Tape in more than 2,200 clinical tests reported the response was “good” to “excellent” in nearly 70 per cent of the cases.
Impervious to moisture, the plastic tape en-
hances diffusion of medication into the skin and allows the steroid to remain effective for extended periods. The medication will not rub off, wash off, or be absorbed by the clothing as is the case with unprotected creams and ointments.
Cordran Tape also helps to protect the skin from scratching, rubbing, drying out, and irrita- tion from handling chemicals.
The tape is made of a thin matte-finish poly- ethylene film which is slightly elastic, highly flexible, and acts as a mechanical splint to fis- sured skin. The medicated adhesive is a syn- thetic copolymer of acrylate ester and acrylic acid, which is free of substances of plant origin. The adhesive surface is covered with a protective pa- per liner to permit handling and trimming before application.
As is true of all corticosteroids, the applica- tion of Cordran Tape is contraindicated in chick- enpox and vaccinia and in patients with a history of hypersensitivity to any of the product’s com- ponents. Cordran Tape is not recommended for use on lesions exuding serum or in intertriginous areas, because such lesions favor bacterial growth.
Its use should be reserved for those cases of dermatoses in which its special features outweigh a possibly higher incidence of adverse reactions.
—The lowest priced tetracycline— nystatin combination available—
MISSISSIPPI STATE MEDICAL ASSOCIATION
Some degree of reaction, usually minor, was ob- served in 18 per cent of cases studied in the clinical trials. Most common side-effects were burning and irritation, 8.3 per cent; folliculitis, 3.8 per cent; and sensitivity reaction, 1.5 per cent. Maceration of the skin, miliaria, and drying oc- curred rarely. In addition, the tape may cause purpura and stripping of the epidermis. If irrita- tion develops, the product should be discontinued and appropriate therapy instituted.
In pregnant patients use of topical steroid products (including Cordran Tape) should be avoided since their safety in such use has not been absolutely established.
Before applying Cordran Tape, the skin should be gently cleaned and dried. Scales, crusts, dried exudates, and any previously used ointments or creams should be removed. After the protective liner is peeled off, the tape is applied while the skin is under gentle tension and then is smoothed down by stroking with moderate pressure to pro- duce tight adhesion.
In most cases, the tape should be replaced after 12 hours, unless the physician directs otherwise. When necessary, the tape may be used at night- time only and removed during the day.
In the clinical trials, 60 per cent of the pa-
1 5
tients received sufficient treatment from one roll of tape, while the requirements of 85 per cent were met by two rolls per patient.
Cordran Tape is supplied in rolls which are 7.5 cm. (3 inches) wide and 200 cm. (80 inches) long. Each square centimeter contains 4 meg. of flurandrenolone.
Ninth Oncology Conference Scheduled
The Ninth National Conference on Therapies for Advanced Cancers will be held Aug. 20-22 (Thurs.-Sat.), 1970, at the University of Wiscon- sin Postgraduate Center in Madison.
The Division of Clinical Oncology, University of Wisconsin, is sponsoring the conference. The chairman is Dr. Fred J. Ansfield, Professor of Clinical Oncology.
Additional information may be obtained by writing the program coordinator: R. J. Samp, M.D., University Hospitals, Madison, Wisconsin 53706.
HIGHLAND HOSPITAL
Asheville, North Carolina
FOUNDED 1904
A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY
Accredited by the Joint Commission on Accreditation and Certified for Medicare
Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho- therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser- vice work with families, family therapy and an extensive and well organized activities program, including oc- cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may be realized.
High school facilities for a limited number of appropriate patients are now available on grounds. The School Program is fully integrated into the hospital treatment program and is accredited through the Asheville School System.
Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.
Brochures and information on financial arrangements available Contact: Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions
or
Charles W. Neville, Jr., M.D.
Assistant Professor of Psychiatry and Medical Director Area Code 704-254-3201
This “case history” runs to some 10,000 pages
This is a typical "case history” of one new drug -or, rather, a proposed new drug — assembled for submis- sion to the U.S. Federal Food and Drug Administration. These volumes are the result of several years’ work by thousands of professional and skilled personnel in just one pharmaceutical company's research labora- tories, and by hundreds of physicians in medical schools, hospitals, and private practice. They cover every aspect of experience with this proposed new agent from chemical laboratory to clinic, from mouse to man. Each volume could conceivably represent hundreds of thousands of dollars of financial invest-
ment, countless hours of human effort. This veritable mountain of data stands behind every new agent offered to you by pharmaceutical manufacturers — a reassuring testimonial to the efficacy, safety and purity of the drugs you will prescribe today to lower the cost of disease to your patients.
Pharmaceutical Manufacturers Association
Pharmaceutical Advertising Council
1155 Fifteenth St., N. W., Washington, D.C. 20005
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
February 1970, Vol. XI, No. 2
Prevention of Maternal Rh Sensitization:
Anti-Rh Immune Globulin
WILLIAM B. WILSON, M.D.
Jackson, Mississippi
Thirty years ago, Dr. Philip Levine, a pupil of Dr. Karl Landsteiner, became interested in a case of an unusual transfusion reaction. This had oc- curred in a woman of blood group O, who had received group O blood. This was, of course, thought to be compatible. Such a reaction was uncommon, but by no means rare. This woman had recently been delivered of a stillborn infant, and because of postpartum hemorrhage, had been transfused with her husband’s blood. Dr. Levine demonstrated an abnormal antibody in the serum of this woman. He surmised that she might have become sensitized to an unknown blood factor in the red cells of her child, which had been inherited by the baby from the father, but which was foreign to the mother. He thought that the antibody which he demonstrated in the mother’s serum was probably an antibody to this factor.
In the next two years, he recognized that these hitherto unexplainable, “intragroup” hemolytic transfusion reactions often occurred in women who had given birth to infants with the syndrome known as erythroblastosis fetalis. He postulated
From the Department of Pathology, Mississippi Baptist Hospital.
Read before the Section on Obstetrics and Gynecology, 101st Annual Session, Mississippi State Medical As- sociation, Biloxi, May 12-15, 1969.
that these infants’ red cells contained an antigen which entered the mother’s circulation and stimu- lated the formation of maternal antibody, which, in turn, crossed the placenta into the fetal circu- lation and destroyed the fetal red cells, produc- ing the syndrome. The responsible antigen was found to be identical with the blood group, new- ly discovered by Landsteiner and Wiener, which they had named the Rhesus or Rh blood group.
In the early 1960s several investigators working independently of each other began research on the hypothesis that passive im- munization of Rh-negative women immedi- ately after delivery of Rh-positive infants could prevent maternal Rh sensitization. The history of study on this subject is traced, and current use of the anti-Rh immune globulin is discussed in detail.
For 50 years, it has been recognized that the administration of antibody concomitantly with antigen would prevent the antigen from stimu- lating antibody production in the recipient. This dates back to the work of Smith,1 who showed, in 1909, that simultaneous administration of diphtheria toxin and antitoxin prevented the de-
53
FEBRUARY 1970
ANTI-Rh GLOBULIN / Wilson
velopment of active host immunity to diphtheria. Since that time, this observation has been amply confirmed with many different antigens, and is a cardinal immunologic principle. In 1960, Finn- proposed that this principle be utilized in pre- vention of maternal Rh sensitization, by admin- istration of anti-Rh antibody to Rh-negative mothers following delivery of Rh-positive in- fants. It was strongly suspected that an Rh-neg- ative mother usually became sensitized to her Rh-positive infant at the time of delivery, by means of a leakage of fetal blood into the ma- ternal circulation at the time of placental separa- tion. Therefore, if administration of anti-Rh anti- body were to succeed in preventing maternal sensitization, it would have the best opportunity of doing so, if given at the time of delivery.
Hamilton,3 in 1962, was the first to try this idea. The results were indeed impressive. He in- jected intravenously a high-titer antiserum into more than 500 Rh-negative women postpartum, and, of 74 who had subsequent Rh-positive preg- nancies, none showed Rh sensitization.
INITIAL EFFORTS
Meanwhile, Finn and Clarke,4 in Liverpool, had begun work on development of a suitable antibody preparation, which they tested first in male volunteers, and then clinically, by injecting it into Rh-negative women immediately after de- livery of Rh-positive infants. At about the same time. Pollack, Gorman, and Freda,5 working in- dependently at Columbia University, initiated an almost identical project based on the same hy- pothesis; namely, that passive immunization of Rh-negative women immediately after delivery of Rh-positive infants could prevent maternal Rh sensitization. In 1966 and 1967, extensive, well-controlled, field trials were carried out in several medical centers in West Germany, Swe- den, Great Britain, Canada, and America, and it was shown that practically every woman given the anti-Rh antibody within 72 hours after de- livery of an Rh-positive infant was protected against development of Rh sensitization.4
In the combined data of these worldwide trials,4 of 1,886 women injected with anti-Rh an- tibody following their first delivery, only four subsequently showed anti-Rh antibodies, repre- senting a failure rate of only 0.2 per cent. Of 2,006 women left uninjected, 149, or 7 per cent, developed demonstrable antibodies within a few months postpartum. However, these re-
sults were not considered the final answer, be- cause of the possibility that some of the sup- posedly protected women had actually received a primary sensitization by their first pregnancy, which was nevertheless undetectable by in vitro antibody titration, and which might become ap- parent only after the stimulus of a second Rh- positive pregnancy. Fortunately, these fears were not substantiated, because, of 245 women who had been given antibody injections following each of two Rh-positive pregnancies, only one, or 0.4 per cent, became demonstrably immunized after the second pregnancy, while of 325 women who were not injected, 41, or 13 per cent, were dem- onstrably immunized following their second preg- nancy.
IMMUNOLOGIC MECHANISM
By what immunologic mechanism does the administration of anti-Rh antibody following de- livery prevent maternal Rh sensitization? The exact mechanism is not known. Mollison0 has suggested that passively administered antibody combines with the antigen and prevents it from combining with receptors of the same specificity on antibody-forming host cells. It has also been shown that if Rh-positive cells are coated with anti-Rh antibody before injection into Rh-nega- tive male volunteers, the formation of immune Rh antibody is prevented.4 Siskind7 has found that passive antibody specifically suppresses an immune response, by binding to the antigenic determinants on the antigen molecule and com- petes with antibody-forming host cells for avail- able antigen. Pollack et al8 found that passively administered antibody competed with the immu- nologically competent cells for antigen (or RNA- antigen complex); or possibly prevented prelim- inary “processing” of antigen by host macro- phages. Clarke4 suggested that the passively ad- ministered antibody acted as a negative feed- back against production of additional antibody by the host, and therefore, if exogenous antibody is administered immediately after antigen, the process of antibody formation by the host never begins.
Why is Rh antibody given only post partum, and not at some time during pregnancy when maternal sensitization might be expected to oc- cur? The statistical data shows that almost all ma- ternal Rh sensitization occurs as a result of trans- placental hemorrhage of fetal blood into the ma- ternal circulation at the time of placental separa- tion, although fetal erythrocytes are demonstra- ble in the maternal blood stream in gradually in-
54
JOURNAL MSMA
creasing numbers from six weeks’ gestation until delivery.9 In spite of the presence of fetal eryth- rocytes in the maternal blood stream during most of the pregnancy, only 0.1 per cent of Rh-nega- tive primiparas developed Rh sensitization be- fore term, according to Pollack, Gorman, and Freda.3 (However, Woodrow and Donohoe10 found that 7 of 760, or 0.9 per cent, of their pa- tients developed Rh antibodies during their