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VOLUME II
January -December, 1961
• EDITOR
William M. Dabney, M.D.
• ASSOCIATE EDITORS
Dewitt W. Hamrick, M.D. George H. Martin, M.D.
• MANAGING EDITOR
Rowland B. Kennedy
• EDITORIAL ASSISTANT
Betty M. Sadler
• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D. Chairman
B. B. O’Mara, M.D.
William E. Lotterhos, M.D. and the Editors
• THE ASSOCIATION
Lawrence W. Long, M.D. President
C. P. Crenshaw, M.D. President-elect
C. G. Sutherland, M.D. Secretary-Treasurer
B. B. O'Mara, M.D.
Speaker
Howard A. Nelson, M.D.
Vice Speaker
Rowland B. Kennedy Executive Secretary
Charles L. Mathews
Assistant Executive Secretary
Mississippi State Medical Association 735 Riverside Drive Jackson
HfALTH 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. Copyught 1961, Mississippi State Medical Association.
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
January 1961, Vol. II, No. 1
Blood Volume Problems In Acutely Injured Patients
LEO J. SCANLON, JR., M.D.
Jackson, Mississippi
Acutely traumatized patients experience blood volume changes that vary with the type of injury.
If the injury is one in which a crushing force has acted upon the body causing relatively little hem- orrhage but extensive muscle contusion, plasma is the main blood component lost. The plasma is also the main blood component lost in severe ther- mal burns.
A different state exists when the injury has severed blood vessels and an external or internal loss of blood is taking place.
Besides blood loss, the circulatory physiology of the body can be disturbed by emotional and sen- sory stimuli such as fear, apprehension, and pain. Injuries to the brain, spinal cord, or lungs should be searched for in a patient with circulatory dys- function following trauma.
The term “shock” has been given many mean- ings by various authors, but most commonly it describes a clinical picture associated with circula- tory hypofunction. The degree of shock in trauma- tized patients generally is directly in proportion to the amount of blood volume. This parallelism be- tween the clinical state and the blood volume is useful in guiding our therapy.
A normal adult male of 150 pounds has ten pints of blood circulating through his vascular
From the Department of Clinical Laboratory Sciences, The University of Mississippi School of Medicine. Read before the Symposium on Trauma, American Col- lege of Surgeons, Jackson, May 10, 1960.
In dealing with acutely traumatized pa- tients, it is essential that need be balanced against the hazards of blood transfusion therapy. The author evaluates the indica- tions for blood plasma and plasma expand- ers and discusses the intrinsic risks of blood transfusion.
system. In an adult there is approximately one pint (500 milliliters) of whole blood per 15 pounds of body weight.
It has been shown1 that successful surgery can be undertaken once the blood volume of an in- jured patient has been restored to 80 per cent of normal.
Based on their World War II experiences with bomb victims, British surgeons1 have defined three phases of blood volume reduction and their cor- responding pictures.
The first or “Normovolemic” phase occurs when the patient’j blood volume has been re- duced, but not below 90 per cent of normal. The blood pressure is above 100 millimeters of mer- cury, and the pulse rate varies between 70 to 100 per minute, with the extremities being warm or normal to touch. No facial pallor is present.
The second phase is termed the “Pattern of Cold Tachycardia” and corresponds to a blood volume between 70 per cent to 80 per cent of
JANUARY 1961
1
BLOOD VOLUME / Scanlon
normal. The systolic blood pressure is still at or above 100 millimeters of mercury, but the pulse rate is greater than 100 per minute. The extrem- ities are cold, and facial pallor is present.
The third phase is termed the “Pattern of Cold Hypotension” and indicates that the blood volume has fallen below 70 per cent of normal. The pulse rate is high, the extremities are cold, and marked facial pallor is present in addition to a systolic blood pressure below 100 millimeters of mercury. This pattern tends to remain until abolished by transfusion. As the blood volume approaches 60 per cent of normal, the pulse becomes impalpable, the cardiac rate is generally above 140 per minute with dyspnea and cold sweating making their ap- pearance. The patient is now at a critical level and unless treated promptly will take the fatal plunge into irreversible shock. When the blood volume falls to about 50 per cent of normal, death occurs.2
IMBALANCE CORRECTION
Having arrived at the decision as to how much fluid has been lost from the vascular system, we proceed toward correcting this imbalance with the appropriate fluid. At our disposal are many agents such as whole blood, packed cells, plasma, dextran 6 per cent in saline, and solutions of human albumin.
The first step prior to any therapy is to draw a sample of venous blood for hematocrit and hem- oglobin determinations and for sending to the blood bank for typing and crossmatching.
If the injury is associated with a high hematocrit and hemoglobin level, then we can assume that plasma loss is taking place and initiate therapy with plasma or dextran. Human albumin solutions, although excellent, are not readily available in many hospitals, and are quite expensive.
A pint of human plasma raises the blood volume by 5 per cent. Thus, for a 70 kilogram man whose blood volume has fallen to 60 per cent of normal, two pints of plasma will be required to bring the blood volume to 70 per cent and four pints for obtaining an 80 per cent blood volume.
Pooled human plasma formerly carried a one in 50 chance of containing the virus of infectious hepatitis. However, the newer technique of pro- longed storage at room temperature is proving successful in eradicating this hazard of plasma. Plasma usage is increasing as the danger of hepa- titis recedes.
Dextran as a 6 per cent solution in normal saline is an adequate plasma expander for use in in- stances when plasma loss is great, as in burns or
crushing injuries. While dextran is beneficial in the emergency phase of shock occurring from i hemorrhage, the resulting anemia should be cor- rected by whole blood. If dextran is started prior to drawing blood for typing and crossmatching, it is sometimes found difficult to crossmatch this blood because of the rouleaux formation often produced. Normally about 25 per cent to 50 per cent of the administered dextran is renally ex- creted within 24 to 48 hours.
PLASMA LOSS GUIDE
As a guide to plasma loss, the degree of hemo- concentration is helpful. A hemoglobin rise to 150 per cent of normal is usually associated with the loss of at least 1,600 milliliters of plasma in a normal sized man.3
There is but one definitive therapy for an in- jured person losing blood: whole blood transfu- sion. The question often arises as to how fast to give whole blood to injured patients. A good rule of thumb is that the dangers of giving whole blood too slowly are greater than giving it too rapidly. In a traumatized patient needing blood, it is recom- mended that one to two pints (units) be given within a 30 to 40 minute period.
Unfortunately, laboratory methods, short of total blood volume studies, are of little help in hemorrhage of short duration. Several hours must elapse before the venous hematocrit reflects the quantity of blood lost.
The rate of restoration of blood volume after hemorrhage was studied by Ebert, Stead, and Gibson, who found that after the loss of about 1,000 milliliters of blood, adults require some 36 hours to restore blood volume.4
CHANCES FOR ERROR
Patients traumatized by wounds or injuries rarely suffer severe pain as they pass into shock- like states, and become less sensitive to noxious stimuli of all types. During the rush and confusion which often accompany the arrival of acutely in- jured patients, the chance of an error in giving blood to the wrong patient or of drawing or mis- labeling the blood sample is highest. Since the in- jured patient often is unable to report the phenom- enon that accompany an incompatible transfusion, the injury would be compounded. For this reason, most pathologists require a Coombs crossmatch on blood for comatose or semicomatose injured pa- tients, as the Coombs crossmatch is the safest and best of all the techniques of crossmatching.
Before closing this discussion on fluid therapy for injured patients, a few pertinent facts concern-
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ing the intrinsic hazards of blood transfusion should be stated. It is now a generally accepted fact that the giving of a single pint of blood carries a mortality rate higher than an appendectomy or the giving of ether as an anesthesia. There is a probability of one death due to transfusion per 2,000 transfusions.5 Other statistics show that in- fectious hepatitis occurs in a ratio of one per 200 transfusions, despite the most meticulous care be- ing taken to select donors. At the University Hos- pital we take a long and involved history from each prospective donor, plus a brief physical ex- amination and a test on each blood for serology, anemia, and hyperbilirubinemia. These facts
should be kept in mind when ordering blood for patients. ★★★
2500 North State Street
REFERENCES
1. Grant, R. T. : Remarks on the Diagnosis and Treat- ment of “Wound Shock” in Limb Injuries, Brit. Med. Bull. 10:13-16, 1954.
2. Wiggers, C. J.: Physiology of Shock, New York, The Commonwealth Fund, 1950, p. 183.
3. Scott, R. B.: Blood Transfusion and the Effects of Injury, Brit. Med. Bull. 10:22-25, 1954.
4. Ebert, R.; Stead, E.; and Gibson, J.: Response of Normal Subjects to Acute Blood Loss, Arch. Int. Med. 68:578, 1941.
5. Crisp, E. C.: “One Pint of Blood” (editorial), Obst. & Gynec. 7:216, 1956.
TRAMPOLINE TROUBLES
Noting the alarming number of injuries and deaths among amateur bouncers, community health departments are becoming concerned about the trampoline fad. Many communities are now drawing up stricter rules for the use and supervision of the mats. Recently, the American Medical Association took an official stand on the ‘“hazards” of the sport and issued a report urging revised controls for commercial use of the trampolines.
According to the report: When maneuvers on the mat are per- formed imperfectly or incompletely, they lead to disaster. The back somersault is named as the most dangerous and most frequent cause of severe injury. (Although both front and back somersaults are cited as dangerous, the back somersault is blamed for the highest number of acute injuries to jumpers’ spinal columns.)
Warns the AMA:
• Extended periods on the mat are not advisable. For the beginner, a half hour at a time is maximum.
• Most dangerous place on the mat is the center. Reason: While critical injury may result from striking the springs or side supports, gravest neurological accidents occur when bouncers land awkwardly in the middle.
• The presence of qualified gymnastics instructors and strict enforcement of them of graduated training programs should be en- forced at all times. In particular, children should have special supervision because they don’t appreciate the risks involved.
The Insider’s Newsletter
JANUARY 1961
3
Treatment of Burns In Limited Medical Facilities
JOHN G. EGGER, M.D., and VIRGINIA S. TOLBERT, M.D.
Drew, Mississippi Ruleville, Mississippi
A newspaper clipping in 1956 read:
“Ruleville, Mississippi (AP) — A 6-year-old Negro girl probably owes her life to the skill and generosity of the staff of the North Sunflower County Hospital. Lucy Mae Fletcher suffered third degree burns over 75 per cent of her body last December when her dress caught fire from a gas heater. The hospital lacked the necessary skin-grafting equipment, but it went out and bought it. Three white staff doctors donated their time and skilled hands. The cost of the treatment, to date, the hospital says has been more than $2,000, exclusive of the fees the doctors waived. Completion of the grafting process will take an- other four months at a cost of another $2,000. Lucy Mae’s father, J. H. Fletcher, said he is ’thankful to be living among people who will do so much when it needs to be done.’ ”
Lucy Mae, 6-year-old Negro female was ad- mitted in a critical condition to North Sunflower County Hospital in Ruleville about 9:45 p.m., Dec. 19, 1955, with a history of having been burned several hours before when her clothes caught fire from an open gas heater. Approx- imately 75 per cent of her body received second and third degree burns involving both arms, fore- arms and hands, the lower anterior and posterior thorax just below the nipple line, the buttocks, hips, perineum, and both lower extremities except for the ankles and the plantar surface of both feet. The bums of the arms and forearms were chiefly first and second degree.
Lucy Mae received emergency debridement and dressings with vaseline gauze and was placed in bed, in shock, expected to die. She received the following orders: diet as tolerated; Elixir Pheno- barbital, 2 drams, if needed, every four hours; aspirin, 5 grains as required; Achromycin, 125
Read before the 74th Semi-Annual Meeting, Delta Med- ical Society, Belzoni, October 12, 1960.
When Lucy Mae Fletcher was first ad- mitted to the North Sunflower County Hos- pital, she was given very little chance of living. Seventy-five per cent of the 6-year-old Negro girl’s body had received second and third degree burns when her dress caught fire from a gas heater. Through skill and what the authors term ” tender loving care,” Lucy Mae is not only alive today but able to walk and attend school. This is her storv.
s
mg. every four hours; Foley catheter drainage; 24 hour fluid intake and output plus sterile bed sheets and heat cradle. Her urinary output was 100 cc. the following morning so fluids via clysis were begun since all veins were collapsed.
Her temperature was subnormal the first four days of hospitalization, taken rectally. Then it began spiking 104 degrees. This temperature av- eraged about 1 02 degrees for the 1 1 week period, spiking from 104 to 105 degrees. She took inade- quate oral fluids, and was given 1,000 cc. 5 per cent glucose in Ringers solution daily by clysis for the next 10 days. On the 10th day a vein was cannulized in an ankle, and she received 500 cc. whole blood plus a continuous slow drip of glu- cose. This was kicked out by the patient four days later while being turned in bed. Her course continued septic with temperature elevations, rig- ors, and numerous complications for the next four months.
On Jan. 17, 1956, the entire plantar surface of her right foot was severely burned when her mother removed the cover from a hot water bot- tle and placed it directly on her skin. This healed in approximately four weeks.
On Jan. 23, 1956, approximately one month after admission to the North Sunflower County
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Hospital, the hospital purchased a Padgett-Hood Dermatone. Lucy then received the first of some 14 separate skin grafts. Bronchial pneumonia promptly followed her general anesthetic, but she responded to therapy.
SINGLE ANSWER: SKIN
The problem at this time was keeping the pa- tient free as possible from infection, and keeping adequate fluid balance due to the extensively burned area completely denuded of skin. After much forethought, discussion, and studying of all burn literature available, the single answer to Lucy’s problem was skin. Lucy Mae’s father hap- pened to have the same type blood, so he was picked as a skin donor and admitted to the hos- pital. On Feb. 8, 1956, under a spinal anesthesia five split thickness skin grafts, approximately 4x8 inches, were taken from the abdomen and thighs of the father and transferred to the raw areas of Lucy’s abdomen and thighs. At the same time, a small split thickness graft was taken from Lucy’s chest and split into many small implants. This resulted in almost complete coverage of the burned areas, and remained viable almost 100 per cent for the following six weeks. This homo- graft from the patient’s father provided a life- saving cover, and over 50 per cent permanently remained viable with an excellent “take.”
GRAFTING TECHNIC
The technique of donor skin preparation con- sisted only of judicious scrubbing with Septisol and cleansing with ether. After taking the skin desired, the site selected for implantation was ir- rigated freely with sterile normal saline, gently scrubbed with gauze, and the implant laid on the area selected. Sterile strips of nylon cloth, satu- rated in normal saline were then laid over the graft, followed by a layer of sterile strips of Fura- cin saturated gauze. Pressure bandages covered by Ace bandages completed the dressing. Large skin grafts were incised longitudinally approxi- mately every few inches to allow escape of serum. Dressings were removed about the fifth day post- operatively and open therapy with heat cradle instituted.
During each grafting operation, small pinpoint “pinch” autografts were taken from the patient’s chest and scattered over any available raw area. General anesthesia was necessary each time, and practically every operation was followed by a period of respiratory infection or bronchial pneu- monia. Lucy also had frequent episodes of tonsil- litis and sore throat. The most serious complica- tions encountered were ulcerations over each fem-
oral trochanter exposing the bone, but fortunately no joint complications were resultant. Large ab- scesses over both deltoid regions of the shoulder resulted from penicillin injections, but these healed without complications.
Due to stool contamination, no attempt was made to epithelize the perineum. It was with a great deal of surprise that after the third month of hospitalization the vaginal and rectal epithelia were found slowly extending in ever widening circles, with no evidence of infection, to eventu- ally cover the perineum in its entirety by the eighth month.
HOSPITAL COURSE
On April 20, 1956, approximately four months after admission, Lucy was able to be lifted into a wheel chair and did not want to get back into bed. On July 7, 1956, she was able to walk with as- sistance and with crutches and was able to crawl to the foot of her bed.
The following Christmas Eve, Dec. 24, 1956, she was allowed a 12 hour visit to her home with her family.
On Jan. 24, 1957, after approximately 13 months of hospitalization, Lucy was sufficiently recovered to be discharged, ambulatory. She had severe bum contracture of her left hip and knee, but the surprising fact was that she was alive and able to walk at all.
During her hospitalization, she received numer- ous antibiotics, multiple dressings with Furacin powder and Furacin dressings, vaseline gauze, Foille, saline soaks and irrigations, open heat cra- dle therapy, hematonics, vitamins, plus numerous other drugs and a total of 22 whole blood trans- fusions.
'TLC’: AN IMPORTANT FACTOR
One of the most important factors with regard to Lucy’s recovery was the “tender loving care” (actually private duty nursing) that the nursing staff of North Sunflower County Hospital pro- vided.
Lucy was referred to the Crippled Children’s Service on May, 1957, and has been under their care since that time. When she was first seen in their clinic, she was reported to have a 45 degree flexion contracture of the right hip, some con- tracture of the right knee, and an equinus deform- ity of the right foot. There were severe adduc- tion contractures of both hips due to burn scars around the genital region.
On Feb. 3, 1958, Lucy was treated at LeBon- heur Hospital in Memphis with excision of the burn scar contracture of the right groin and ap-
JANUARY 1961
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BURNS / Egger and Tolbert
plication of a large, thick, split thickness skin graft. There was good result from this procedure. It was reported at that time that due to the con- tracture she had a chronic dislocation of the right hip.
On March 25, 1958, the same excision and grafting procedure was performed on the left groin with good results.
On Dec. 16, 1958, surgery was performed on the right hip with osteotomy and plate put in place.
On Feb. 4, 1959, further surgery was per- formed with tendo achillis lengthening; posterior capsulotomy; anterior transfer of the right pos- terior tibial tendon. This procedure was quite suc- cessful with only slight skin slough in the region of the Achilles tendon. She was put into a double upright short leg brace.
On May 30, 1959, Lucy was seen in the clinic for a check-up with range of motion from 80 to 90 degrees in the right ankle. She was ambulated on crutches without weight bearing on the lower extremity. Her progress was considered satisfac- tory.
On Sept. 21, 1959, Lucy was again seen in the clinic for follow-up evaluation. It was felt that she had a serviceable range of motion of the right hip. The right ankle could be brought to 90 de- grees. Her gait was much improved. At that time they stated she had a pelvic support osteotomy
and transfer of post tibial tendon. An elevation was placed on the right shoe.
Check-up x-rays on Dec. 21, 1959, showed osteotomy site with solid bony union. There was a 4 Vi cm. shortening of the right lower extremity. She was given an elevation on the right shoe, a brace, and was told to try walking with only one crutch.
Check-up March 21, 1960, showed Lucy to be in good condition except that leg length discrep- ancy was at that time 7 cm.
April 27, 1960, the progressive increase of leg length discrepancy was discussed with Lucy’s mother, who preferred to have surgical treatment of the child for this condition. She was, therefore, scheduled for hospitalization in July at which time it was planned to perform lower femoral and upper tibial and fibular epiphysiodesis. This sur- gery was performed Aug. 2, 1960, with an un- eventful postoperative course. She was put in a posterior plaster splint.
Clinic check-up on Sept. 19, 1960, disclosed good results from surgical procedures. She was to be allowed full weight bearing with crutches pro- ceeding to full weight bearing. She requires a strap attachment to her brace with a lift on her right shoe. A report from her relatives stated that Lucy is attending school, getting along well and thor- oughly enjoying living. ***
169 South Main Street (Dr. Egger)
SIMPLY SEMI
Semi-private? Semi-demi!
Nomenclature misbegot!
How can privacy be semi?
Private’s private or it’s not.
Soon we’ll have for countless millions Other semi-private pearls:
Semi-lying-in pavilions Serving semi-pregnant girls!
— Corinna Marsh
(Reprinted from Good Housekeeping magazine. © 1960, by The Hearst Corporation, all rights reserved.)
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Case Report IV of Maternal Mortality Study: Hemorrhage Due to Abruptio Placentae
WILLIAM E. NOBLIN, JR., M.D.
Jackson, Mississippi
The following case report, presented by the Committee on Maternal and Child Care, repre- sents death from hemorrhage due to abruptio placentae.
CASE NO. 179-11650-59
W. A. C., a 35-year-old Negro female, para 14, was first seen in the hospital emergency ward. Her expected date of confinement was uncertain, but estimates suggested that she was at about 36 weeks of pregnancy. She had been seen previously on two occasions in the County Health Depart- ment Prenatal Clinic during her eighth month of pregnancy (information obtained later). Hyper- tension (blood pressure 200/110) was noted and the patient was advised and urged on both oc- casions to see a private physician for treatment. History obtained in the clinic revealed that she had had high blood pressure during her last two pregnancies with “kidney trouble.” She had a positive serology 10 years previously and had re- ceived adequate treatment at a public health cen- ter for late latent syphilis.
At the time she was seen she complained of ab- dominal pain and vaginal bleeding. Her blood pressure was 200/1 10 and edema of the face and hands (1+) and of the feet (3+) were noted. There was no albuminuria. Her hemoglobin was 70 per cent.
Following admission the patient apparently went into labor independently with spontaneous rupture of the membranes. Labor lasted five hours during which vaginal bleeding continued. A spon- taneous vaginal delivery occurred from an occiput anterior position of a premature infant weighing 4 pounds, 12 ounces. No lacerations were noted. The patient received Raudixin (100 mg.) and Demerol and Sparine (50 mg. each) during labor. Following delivery, vaginal bleeding continued
Preventive medicine member, Committee on Maternal
and Child Care.
Case No. 179-11650-59 entered the hospital emergency ward at about 36 weeks of preg- nancy complaining of abdominal pain and vaginal bleeding. Labor began spontaneously and after five hours resulted in the birth of a live infant. Vaginal bleeding continued despite the administration of oxytocics and packing of the uterus on three separate oc- casions. Eight hours later the patient died. The findings of the Committee on Maternal and Child Care are discussed in this report.
until the patient's death eight hours later. During this time the uterus was packed on three occasions and the patient received 10 pints of blood and various vasopressors. The cause of death was stated to be premature separation of the placenta.
CASE REVIEW
This case was reviewed by the Committee on Ma- ternal and Child Care at its regular quarterly meeting and the following evaluations made:
I. Adequacy of data. The data obtained in the case were rated 2 on a scale of 1 (minimal) to 5 (com- pleted data sheet, relevant explanatory note, and autopsy report).
II. Cause of Death. This case was considered to be a direct obstetrical death due to hemorrhage from abruptio placentae. Because of the sketchiness of the record, there was some doubt as to the actual cause of death.
III. Avoidability. In ascertaining avoidability, the committee, following the AMA Guide for Maternal Death Studies, assumes ( 1 ) that the physician pos- sessed all the knowledge currently available and relevant to the factors involved in the death. (2) that he had a high level of technical ability by experience, and (3) that he had available to him all the facilities present in a well-organized and properly equipped hospital.
JANUARY 1961
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CASE REPORT IV / Noblin
It is realized that these are extremely strict criteria and that a majority of maternal deaths occur under far less desirable circumstances. However, if maternal care is to be improved, high standards must be main- tained, Therefore, on this basis the committee felt that this death was avoidable.
IV. Factors of Avoidability. If a death is con- sidered avoidable, the committee attempts to assign factors of avoidability to the physician, hospital, pa- tient or a combination of these. In this case, the com- mittee felt that avoidability should be assigned in all three areas. The patient neglected to follow the advice given her by the Public Health Prenatal Clinic. There was a real question, from the record, as to whether adequate facilities were available in the hos- pital for dealing with this type of obstetrical emer- gency. Finally, professional judgment was involved as regards the management of bleeding at the end of pregnancy and of serious postpartal hemorrhage.
DISCUSSION
Although the committee assigned the cause of death to abruptio placentae, this diagnosis was presumptive. More adequate clinical information and particularly the performance of an autopsy might have been of considerable help in this re- spect. There might have been other causes for the postpartal bleeding such as uterine atony, genital tract lacerations, retained secundines, or even a blood dyscrasia.
This patient’s problem undoubtedly started long before she became pregnant for the last time. A grand multipara, she had developed hypertension in her previous two pregnancies. This should have alerted both her and her medical attendants to the dangers inherent in her becoming pregnant once more. Methods of preventing such a pregnancy should have been suggested to the patient and should have been carried out. During her present pregnancy she should have received care early and regularly. When she did finally report to the Pub- lic Health Clinic, she was advised that she needed medical treatment and refused this advice.
When a patient such as this presents herself at the hospital, definite steps must be taken to es- tablish a diagnosis. Bleeding in the last trimester of pregnancy is a serious matter. The patient should be typed and cross-matched for at least 1000 cc. of blood. When this is available, if she is at or near term, she should be taken to the operating room. With everything in readiness to perform a cesarean section if necessary, a careful vaginal ex- amination is performed. In addition, since one of the serious complications of abruptio placentae is hypofibrinogenemia, a tube of blood should be drawn for a clot observation test and this should be repeated at regular intervals.
If the diagnosis of abruptio placentae is es- tablished, then rapid delivery is desirable. This patient apparently did have a fairly rapid and spontaneous labor and delivery of a living child. The fetal mortality in abruptio placentae is very high so that in this respect the case had a satis- factory outcome.
Following delivery, the patient began to bleed. Oxytocics were apparently given but the type and amount were not stated. If oxytocics fail, then it is mandatory that the patient be taken back to the delivery room and examined under aseptic precautions to exclude the presence of a lacera- tion or retained placental fragments. If none of these are found and the uterus still fails to contract in response to intravenous oxytocics, on certain occasions it is useful to pack the uterus. With continued bleeding, it is extremely important to be sure that the patient does not have a blood dyscrasia and repeated clot observation tests and a coagulogram should be performed at this time. In this connection, a hospital in which obstetrical cases are handled should have a supply of fibrino- gen which is immediately available or which can be obtained within a short period of time. Al- though we have no evidence in this case that there was a deficiency of fibrinogen, this might well have occurred. If the uterus has been packed once and bleeding occurs through the packing, there is no point in packing it again. The only thing that will save the patient at this point is massive trans- fusions and hysterectomy. Since this particular patient did not die until eight hours after delivery, it would appear that there was sufficient time to have performed a hysterectomy.
SUMMARY
A maternal death is described in which post- partal hemorrhage following abruptio placentae appeared to be the major cause of death.
Patients who have vaginal bleeding at or near term should be examined under aseptic precau- tions in the operating room with preparations made for cesarean section and with compatible blood available. A clot observation test is an es- sential accompaniment of such preparations.
Postpartal bleeding which does not respond im- mediately to oxytocics makes a careful re-exami- nation of the genital tract under aseptic precau- tions mandatory.
On rare occasions intrauterine packing may be useful in controlling postpartal hemorrhage but should not be repeated. Failure of a pack to arrest bleeding is an indication for massive transfusion and emergency hysterectomy. ***
2423 North State Street
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Clinicopathological Conference XII
Conducted by the Department of Pathology Mississippi Baptist Hospital Jackson, Mississippi
A 61-year-old white man was admitted to the Baptist Hospital on June 29, 1960, with the chief complaints of progressive weakness and numbness. He gave a history of progressively increasing numbness and paresthesias with burning sensa- tion involving the distal one third of the feet, par- ticularly the soles, and both hands, especially the fingers. These symptoms began about four months prior to admission. The onset initially involved only the tips of the fingers of the left hand. How- ever, one month later similar involvement became apparent in the right hand and one month prior to admission the lips and the tip of tongue became involved. He described this sensation, especially in the fingers, as feeling like he was “holding sand.” There had also been associated weakness of both hands and marked difficulty in maintaining his equilibrium.
He stated that unless he held on to objects he felt that he would actually fall forward or to either side. The latter equilibrium disturbance had been more prominent for the past week. He was of the opinion that he could not tell where his hands or feet were. The derangement in the tip of his tongue was accompanied by absence of taste in this area. When he swallowed food, he could taste the food only posteriorly with respect to the tongue’s surface. About two weeks before, he was first found to have an elevated blood pressure at which time he was treated with Diupress. After taking three doses, he noticed severe abdominal cramping and temporarily discontinued the prep- aration. He was later able to take two or three doses without difficulty.
Past history revealed that about three years be- fore he had had some type of fungus infection of the finger nails involving the fingers of the left hand and also had a similar patch on the right side. He stated that 15 years earlier he had had “ulcerated stomach.” In 1917 he had had an in- fection of the penis which necessitated circum- cision. For the past 15 years he had been aware of
CPC XII marks Journal MSMA’s second year of presenting case discussions from Mississippi hospitals. During the past year, case records from the Mississippi Baptist Hospital, the University of Mississippi Teaching Hospital, and the Veterans Ad- ministration Center have been reported.
The subject of January’s CPC is a 61- year -old white man who was admitted to the Baptist Hospital with complaints of pro- gressively increasing numbness and pares- thesias. The initial symptom was a burning sensation involving the distal one-third of the feet, particularly the soles, and both hands, especially the fingers. Later, his lips and the tip of his tongue were also affected. Two months after the original admission, the patient went into a coma and died. The clinical discussion is by Dr. Lucien R. Hodg- es. Dr. Louis Schiesari prepared the autopsy report.
“choking when eating dry foods such as bread crumbs or chicken.” Otherwise, system review and past history were not contributory. The examina- tion revealed a well-developed, well-nourished white male of about the stated age with obvious difficulty with respect to muscle power as noted by his moving about clumsily in bed and with some flexure deformity involving little and ring fingers of the left hand. The blood pressure was 140-150 over 90-100 (right arm) and 200/110 (left arm). All peripheral pulses were palpable and pulsatile. The heart was not enlarged to palpation or percussion and the rhythm was reg- ular.
A grade II holosystolic murmur was present over the aortic area with transmission into the right side of the neck and along the left sternal
JANUARY 1961
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CPC / Baptist Hospital
border to a lesser degree. The second aortic sound was accentuated. There were no signs of conges- tive heart failure. The electrocardiogram showed myocardial damage most probably secondary to hypertension. There was no evidence of myocar- dial infarction. The neurological examination re- vealed definite and marked weakness in the grips of both hands, a markedly positive Romberg's sign, and absence of all deep tendon reflexes. There was an exaggerated burning pain sensation on pressure over the soles of the feet, and the tips of the fingers and the finger to nose touching was impaired.
LABORATORY DATA
The hemogram revealed a hemoglobin of 17.3 grams per cent, a hematocrit of 51 volume per cent and a total white blood count of 17,450 with 61 neutrophils, 6 eosinophils, 28 lymphocytes, and 5 monocytes. The urinalysis was negative. The admission biochemistry data were as follows: cal- cium— 9.4 milligrams; C02 combining power — 63.6 volume per cent; chlorides — 101 mEq per liter; glucose — 78 milligrams per cent; potassium — 3.3 mEq per liter; sodium — 138 mEq per liter; creatine — 1.3 milligrams per cent; urea nitrogen — 33 milligrams per cent. The VDRL was nega- tive. The spinal fluid showed a total protein of 105 milligrams per cent, with 3 lymphocytes, a gold curve of 1112221000, and a negative serology. X-ray studies of chest, small and large intestine, and gallbladder were negative. An excretory uro- gram showed good urinary function. A myelo- graphic study was unsatisfactory. There was noted moderate hypertrophic arthritis of lower cervical area.
READMISSION EXAMINATION
He was discharged and readmitted on Aug. 9, 1960, at which time the total protein of spinal fluid was 350 milligrams per cent with 187 white blood cells per cubic millimeter with 23 per cent polymorphonuclear leukocytes and 77 lympho- cytes. A myelogram done this time showed the space to be patent with escape of the dye into the cranial cavity. In the interval there was noted a progressive deterioration of the previously noted signs and symptoms without appearance of new manifestations. His last admission was on Aug. 24, 1960, at which time he was in marked respiratory distress, breathing being maintained only with difficulty by poor employment of the accessory muscles of respiration. He was placed in a respira-
tor but steady and rapid deterioration ensued into coma and death on Aug. 27, 1960.
CLINICAL DISCUSSION
Dr. Lucien R. Hodges: “This case concerns a 61 -year-old white man with the chief complaints of progressive numbness and weakness, who ex- pired approximately two months from the time of his first admission. His initial complaints were of progressively increasing numbness and pares- thesias with a burning sensation involving the dis- tal one-third of the feet (soles), both hands and fingers, these symptoms having begun about four months prior to admission. He also had sensory involvement of the tip of the tongue and described the sensation in the fingers as feeling as if he were holding sand. He had some equilibrium disturb- ances in that it was difficult to maintain his bal- ance, falling forward or to either side unless he held to an object. These difficulties had been more prominent within the past weeks. He could not tell where his hands or feet were situated. I think the next most important statement is that when he swallowed food he could not taste it on the anterior aspect of his tongue. About two weeks previously he was first found to have an elevated blood pres- sure.
DIAGNOSTIC POSSIBILITIES
“In noting the history of this patient, the first thing that is suggestive is some kind of neuritis with paresthesias and numbness of his hand. Go- ing a little further, it suggests either an involve- ment of the posterior columns, cerebellum, or the spinal ganglia in that he had difficulty with equi- librium. Further, the derangement of sensation of taste and some numbness around the lips suggest cranial nerve involvement. The fifth cranial nerve would affect the numbness around his lip and the chorda tympani, a branch of the seventh nerve, would involve the taste of the tip of his tongue. It is not stated whether the tip of the tongue was anesthetic or hypesthetic, either one.
“The next thing that we note is that he was found to have an elevated blood pressure and, ac- cording to protocol, this was not present before this illness began, or either he had not been to a doctor. I believe that we are dealing with some- thing that, first, involves the peripheral nerves and, second, may either be involving the spinal ganglia, posterior columns, or cerebellum, and thirdly, something involving the sensory nucleus of the fifth nerve and the ganglia of the seventh nerve, and also brainstem involvement. I would say brainstem involvement because he did not
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have any evidence of an elevated blood pressure before the present illness began. So, as far as the history is concerned, the present illness includes peripheral neuritis, possible involvement of the spinal cord and brain stem in the lower portion at and below the pons.
PAST HISTORY
“His past history reveals that approximately three years ago he had had some type of fungus infection of the finger nails on the left hand and also some on the right hand. What happened to this is unknown. Otherwise he had had an ulcer- ated stomach and in 1917 an infection of the penis which required circumcision. This brings out the possibility that this might be some type of neuro- vascular syphilis. The next statement is that he had been aware of a choking sensation when eating dry foods, such as bread crumbs or chicken, and this had been present for 15 years. I would think for that to be of any significance, more symptoms should have followed within the 15 year interval and, therefore, will disregard it.
“The examination revealed a well-developed white male, appearing of the stated age, with some obvious difficulty in respect to muscle power, as noted by his moving about clumsily in bed, with some flexure deformity. The fact that he moved about clumsily does not mean that he had weak- ness in his extremities, but, upon examining furth- er the protocol, I believe it indicates that he did have weakness in the grip of both hands. The flex- ure deformities involving the little and ring fingers of the left hand probably are the result of some previous injury.
CARDIOVASCULAR SYSTEM
“The blood pressure was 140-150/90-100 in the right arm and 200/110 in the left arm. I will re- serve any comment on this finding. All of his peripheral pulses were palpable and pulsatile. The heart was not enlarged and he had a grade II holosystolic murmur over the aortic area with transmission into the neck. I believe this would most likely signify that he had some aortic ste- nosis, and with his hypertension, I would think that this is on the basis of arteriosclerosis. There were no signs of congestive heart failure. The only ‘hooker’ in this situation is that he does not have any cardiac enlargement. The electrocardiogram showed myocardial damage, most probably secon- dary to hypertension. Apparently, all these find- ings are new changes in this man. Either we can discount his story about the hypertension or con- sider it to be something to be involved in his pres- ent illness.
“The neurological examination revealed a defi- nite and marked weakness in both hands. Here we must consider whether or not this might be an amyotrophic lateral sclerosis or involvement of the anterior lateral horn cells. The protocol does not mention whether or not he had any fascicula- tions or atrophy. Another entity that I think we must include is a progressive muscular atrophy. Ordinarily with amyotrophic lateral sclerosis the deep tendon reflexes may be hyperactive in the be- ginning of the disease, and then later become hypoactive or absent. On the basis that there is no mention of there being any muscular atrophy, no fibrillations or fasciculations in the skeletal mus- cles, we may almost exclude this entity. Another factor that might exclude amyotrophic lateral sclerosis or progressive spinal atrophy is the fact that he had sensory involvement. It is almost un- known to have a sensory involvement along with a purely motor disease.
POSITIVE ROMBERG’S SIGN
“The next thing that comes up is the markedly positive Romberg and the finger-nose test being impaired. This can be impaired on the basis of two things: a spinal cord disease or a cerebellar disease. Without going into the laboratory work on this patient, the only thing that keeps me from placing this disease in the high cervical region or in the cervical region itself, is the fact that he had involvement of taste and the fifth nerve. There is no involvement of the seventh nerve, except for the nerve of taste, which comes from the nucleus solitarius, there being no involvement of the mus- cles of the face. Here again we are plagued with whether or not this is peripheral in the geniculate ganglion for taste, the gasserian ganglion for sen- sation, or in the high spinal cord itself, or in the pons, in the tracts, to give him these difficulties.
SPINAL CORD LESION
“If these could be excluded. 1 believe it could be placed on the basis of some spinal cord lesion, such as a tumor, either metastatic or one arising around the foramen magnum. This lesion was then some type of peripheral involvement, either involving the peripheral nerves themselves, the spinal ganglia and/or the spinal cord. With de- creased reflexes one would almost have to con- sider involvement of the peripheral motor system or anterior horn cells, with practically complete destruction. Even with poliomyelitis there is prac- tically never complete destruction of all the ante- rior horn cells, so that the patient will have some reflex left and also some motor power left. Here,
JANUARY 1961
11
CPC / Baptist Hospital
this patient has motor power in all extremities distally, but his grip is weak.
REVIEW OF LAB WORK
“The hemogram revealed a hemoglobin of 17.3 grams per cent and a hematocrit of 5 1 volume per cent. In polycythemia vera it is ordinarily a little higher than this, around 20 grams, with a hematocrit of 55 to 60 volume per cent. Here one must think of some type of vascular shunt, as far as the nervous system is concerned, or perhaps some type of vascular cerebellar tumor or an arteriovenous malformation about the cerebellum. The white blood count was 17,450, which I am at a loss to explain because there is no history of a systemic infection or systemic illness, other than his neurological involvement. This is rather high for a peripheral neuritis. The differential was es- sentially normal except for the presence of the eosinophils, and here 1 think one must think of some of the lower organisms that would cause this, or either this is a laboratory error — and the laboratory does not make errors. The laboratory reported that his chemistries were negative except for the urea nitrogen, which was 33 milligrams per cent. Here we have to think of some genito- urinary tract involvement, perhaps from his hyper- tension.
VDRL : NEGATIVE
“The VDRL was negative. I would much rather see a Wassermann than a VDRL on this patient, but since this test was not done I will assume the VDRL to rule out syphilitic involvement. The most important finding was the spinal fluid protein, which was 105 milligrams per cent, with a cell count of 3 lymphocytes. The colloidal gold curve was negative and the serology on the spinal fluid was negative. With the total spinal fluid protein of 105 milligrams per cent we always have to con- sider some type of lesion, either causing a block or one producing an excessive amount of spinal fluid protein. The most likely one that would cause this is the Guillain-Barre syndrome, especially with the reduction of cells. In Guillain-Barre, or, if you like, Landry’s ascending paralysis, there is dissociation of spinal fluid protein and cells; that is, the protein is high and the cell count is low. X-ray studies of the chest, small and large bowels, and gallbladder were negative.
“A myelogram was done, which was unsatis- factory. The myelogram could have been unsatis- factory for several reasons. The foremost reason could be that the arachnoid space was collapsed
from the previous lumbar puncture. The other reason is that occasionally we see tumors involving the cauda equina which would prevent getting con- trast media into the spinal canal. It is noted that he had hypertrophic arthritis of the lower spine, but very rarely do we find sensory involvement such as this man has demonstrated with this dis- order. One may see muscular atrophy, some fas- ciculations and disturbance of gait, but these changes are over a long period of time and very slowly progressive, and are usually associated with cervical hypertrophic arthritis. Occasionally these signs due to hypertrophic arthritis have been called amyotrophic lateral sclerosis, but in the course of the latter the patient is usually dead within three years, with exceptions of course. I do not believe it varies more than one or two years. Another thing one would expect is the presence of considerable fasciculations in his muscles and considerable atrophy from anterior horn cell de- generation.
DISCHARGE WITHOUT DIAGNOSIS
“Following the myelogram, apparently no diag- nosis was made, and he was discharged from the hospital. He was readmitted on Aug. 9, at which time the total spinal fluid protein was 350 milli- grams per cent with 187 white blood cells per cubic millimeter, 77 per cent of which were lym- phocytes. The fact that his spinal fluid protein had increased from 105 milligram per cent to 350 milligram per cent is highly suggestive of Guillain- Barre’s disease, where there is a protein cell count dissociation with the spinal fluid protein often being normal in the beginning and subsequently developing high levels. The only ‘hooker’ in this is the cell count.
GUILLAIN-BARRE’S disease
“In reviewing some of the literature on Guillain- Barre’s disease, it is found that most often the cell count is normal or is less than five, although it can be 100 or more cells. 1 think it depends more on when the spinal tap is done. If I am asked when is the optimal time to do the spinal tap, the answer is, I do not know. Other things that should be con- sidered are some types of neurological diseases that would cause an increased lymphocytic cell count and among these we encounter some forms of encephalitis or viral myelitis. Again, a myelo- gram was attempted without success and in the interval there was some progressive deterioration of all his signs, without any appearance of other manifestations.
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“His last admission was an Aug. 24, at which time he was in marked respiratory distress. This gives us two clues: one that he has had severe in- volvement of all the intercostal musculature in- nervation from the spinal cord, or that he has had some bulbar disease. His respiration was main- tained only with extreme difficulty, with poor em- ployment of the accessory muscles of respiration, which would make one think of cervical or tho- racic cord involvement affecting the muscles of the diaphragm and rib cage. He was then placed in the respirator and had steady, rapid deterioration and died in coma on Aug. 27. The total time period of the disease is two months, from the time of admission, with the history going back four months.
POSSIBLE CAUSES
“To make a diagnosis on this patient, 1 think we have to boil it down to whether this is a degen- erative infectious, neoplastic, or toxic disease, and I think we can rule out the latter. I saw this man and there was no history of a toxic process to be elicited. I think we would have to include syphilis because of the lesion that was resected in 1917. Also, Landry’s or Guillain-Barre type syndrome must be included because of the fact that it us- ually follows some type of systemic illness, such as infectious mononucleosis or some other tangent illness for which the patient perhaps did not seek medical attention and certainly was not hospital- ized. We have no history of such a situation, but it must be considered that Guillain-Barre’s disease can cause the above findings.
OTHER CONSIDERATIONS
“There are several other things I think we should consider, such as periarteritis nodosa and lupus erythematosum. Ordinarily with these dis- eases there is more encephalopathy than this pa- tient has had, which would have to arise from in- volvement of the vessels about the brain stem and cervical cord, where I believe most of this man’s difficulty was located, although he did have some peripheral nerve involvement. I think we can ex- clude a toxic process, a syphilitic etiology, or other infectious process on that basis. We have to in- volve the cerebellum in that the patient has had impairment of finger-nose testing and positive Romberg tests. We can also exclude the cere- bellum on the basis that this is purely a spinal in- volvement and does not involve the cerebellum at all.
“Despite the fact that he could not tell where his feet were located, he still might be able to per- form the finger-nose test quite well, as long as he
could see his hand or the Romberg may not be positive with his eyes open. It does not indicate whether the eyes were opened or closed in the protocol, but he has no other cerebellar symptoms. Again, I saw this man and I felt strongly that this was a spinal ataxia, the other cerebellar functions being completely intact. The only things that I cannot explain are the elevated white count along with some type of peripheral neuritis, the involve- ment of taste, and the sensation of numbness around his lips. Sensations of taste involve the geniculate ganglion, which could be affected in this polyneuritic disease. The fifth nerve involve- ment could have been involved on the same basis, but still could have been involved on the basis of bulbar symptoms. Later on, during his second ad- mission, myelograms were done which were suc- cessful enough to show the dye within the cranial cavity, without any sign of a block. I think this alone fairly well rules out a spinal cord tumor, though not absolutely.
DEGENERATIVE DISEASES
“The one category I have not mentioned is the degenerative diseases, and I think we can exclude these on the basis of: (1) there was no motor in- volvement other than his subjective and objective weakness, and (2) there were no atrophy or mus- cular fasciculations. This, I believe, would exclude amyotrophic lateral sclerosis or a progressive spinal atrophy. A syphilitic process, I think, can be ex- cluded on the basis of his spinal fluid studies, al- though these are not positive in about 30 to 40 per cent of the cases, and again there is a long time lapse since 1917, with no symptoms during this time, and ordinarily the symptoms do occur earlier than 60 years of age. He has no evidence of a general paresis which one would expect with syphilis over this length of time.
“My diagnosis is that this is Guillain-Barre’s disease on the basis of a progressive illness, an in- crease in spinal fluid protein, regardless of the cell count, and the fact that he had bulbar in- volvement along with peripheral nerve and per- haps spinal ganglia and/or spinal cord involve- ment.”
AUTOPSY REPORT
Dr. Louis Schiesari: “At autopsy there was atelec- tasis of the lower lobes. The brain and the entire spi- nal cord removed with the dura mater and spinal ganglia attached were grossly not remarkable. The microscopic examination of the brain revealed only sparse perivascular collections of lymphocytes predominantly in the white matter and subependy- mal layers and occasional foci of lymphocytic in-
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JANUARY 1961
CPC / Baptist Hospital
filtration with degeneration. In the spinal cord there was chromatolysis, dissolution or complete disappearance of the anterior horn cells, altera- tions to be ascribed to the axonal degeneration. A
Figure 7. Lymphocytic reaction around pial ves- sels of spinal cord.
heavy infiltration of lymphocytes was noted along the pia mater of the spinal cord where capillaries and small vessels were surrounded by a thick coat of cellular exudate. The roots of the spinal ganglia and the peripheral nerves were affected to about the same extent. There was severe edema of the myelin sheaths which appeared beaded and swollen and a moderate lymphocytic reaction. In the areas of maximal damage myelin sheaths and axis cylinders had disappeared. Proliferation of Schwann’s cells was evident in most of the sec-
tions and occasionally macrophagic reaction was encountered.
“It is evident that both the central and periph- eral nervous systems were involved simultaneously, although to various degrees. Thus we are dealing here with some sort of myelopolyradiculoneuritis, the microscopical changes of which are neither specific or diagnostic. I feel, however, that when these alterations are correlated with the spinal fluid abnormalities and the clinical manifestations, the diagnosis of Guillain-Barre syndrome, pro- posed by Dr. Hodges, can be sustained. Since the course was characterized by a progressive ascend- ing paralysis with fatal termination, I think that Landry Guillain-Barre is the appropriate term.
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Figure 3. Peripheral nerve. There is scant inflam- matory reaction, and degenerative changes predomi- nate. Note swelling, fragmentation, and disappearance of myelin sheaths and axis cylinders.
Figure 2. Cross sections of the cauda equina. Sparse lymphocytic infiltration of arachnoid with edema and macrophagic reaction.
“The causes of this syndrome are still obscure. Quite a few cases complicating infectious mono- nucleosis have been reported, but in most instances the syndrome appeared as an isolated clinical en- tity. Virus and bacteriological studies have been negative. It is of interest to mention that malignant hypertension developed during the course of ill- ness in about one-fifth of the cases, and it has been suggested that this complication could be re- lated to the involvement of the spinal roots.’’
1190 North State Street
REFERENCES
1. Haymaker, W., and Kernohan, J. W.: The Landry- Guillain-Barre Syndrome, Medicine 28:59-141 (Feb.) 1949.
2. Jackson, R. H.; Miller, H.; and Schapira, K.: Poly- radiculitis (Landry-Guillan-Barre Syndrome) Brit. M. J. 1:480-484 (March) 1957.
14
JOURNAL MSMA
Medical Education in Mississippi
Part I of HI
ZEB VANCE BAUCUM, M.D.
Jackson, Mississippi
The University of Mississippi School of Medi- cine and Hospital stands today as one of the most beautiful, modern, and well-equipped medical fa- cilities in the world. It is located in Jackson, Miss., on a rolling, spacious plot of 600 acres near the intersection of Woodrow Wilson Drive and North State Street. On this same land once stood the Mississippi State Asylum and, later, the Highway Safety Patrol. The principal structure towers seven stories above a spacious basement level, standing as evidence of the courage, ingenuity, planning, and hard work which made it possible. Today, Mississippi can be proud of this institution, but it was not always this way. . . .
With the possible exception of clergymen, who served as America’s earliest “medical men,” Mis- sissippi’s early medical history parallels that of the nation in general, although the state lagged some- what behind in point of time. This is not offered as criticism, because, in fact, the first medical school (the Medical College of Philadelphia, now the University of Pennsylvania School of Med- icine) was established in the United States in 1765 and Mississippi did not become a state until 1817.
A comparative study of Mississippi’s medical progress with that of the United States in general is analogous to comparative embryology or com- parative anatomy. Thus, the earliest formally trained physicians in the United States were of necessity educated in foreign countries. Likewise, Mississippi’s earliest formally trained physicians were educated on “foreign” soil, primarily, of course, in neighboring states but in other states and some foreign countries as well. What might be considered another comparative era was the train- ing of physicians by preceptorship. As this was true of early America, so was it true of early
With its dedication on July 1, 1955, the University of Mississippi School of Medicine became a focal point for Mississippi medi- cine. As it is located only a short distance from three hospitals, both state and county health departments, the headquarters office of MSMA, and numerous other medically centered agencies, it stands as both a phys- ical and symbolic hub of state medical ac- tivity.
Tied up in the University School of Medi- cine and Hospital is the entire history of medical education in the state. The story begins with the clergymen, America’s first " medical men,” and continues through the "diploma mills ” to the present.
Part I is presented in this issue with parts II and III to follow in the February and March Journals. Dr. Baucum, who was grad- uated from the University in June, 1960, wrote the paper as his senior thesis.
Mississippi. Paralleling this era was the practice of persons simply “adopting” the title of “doctor” and assuming medical practice with little training. This was possible because of the early lack of legal control.
The next step in medical education was the es- tablishment of “diploma mills” or “second rate” medical schools. This practice flourished primarily during the last half of the 19th century but carried over to the first few years of the 20th century. While the practice was more popular in other states, it entered Mississippi with the establish- ment of the now defunct Mississippi Medical Col-
JANUARY 1961
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MEDICAL EDUCATION / Baucum
lege in Meridian. It is not the purpose of this paper to state whether this school was intended as such or whether it was the victim of circumstances, but to say it was so intended would be an unjust state- ment without any basis in fact. Another example is the long since defunct and almost completely forgotten Meridian Medical College which existed more than two decades before the Mississippi Medical College.
Many of these schools were organized and op- erated by private physicians and most of them were without university affiliation. There were few standards for the quality of education and most of the schools were operated for profit or prestige.
GROWTH OF SCHOOLS
The number of schools grew rapidly during this period. In 1 800 there were only four medical schools operating in what was then the United States. By 1899 there were 156 medical schools of all types in addition to 10 graduate medical schools which were chiefly concerned with the teaching of specialty courses. This total does not include the nearly 350 medical schools that were opened during the 19th century but ceased opera- tion before the turn of the 20th century.
Of the 156 schools operating in 1899, only one, Johns Hopkins University, required a college de- gree for admission. Other schools’ admission re- quirements ranged from ability to pay the tuition fee through varying amounts of premedical train- ing.
It is not a truism that all proprietary schools were bad and all university schools were good. No doubt some of the proprietary schools were operated by conscientious persons sincerely inter- ested in offering a good medical teaching program. Moreover, of the 74 medical schools operated as departments of universities or colleges, probably close to one-half were deficient in one way or another, and were often treated as the “orphans” of the university. Many of the university schools had just as inadequate admission requirements as the proprietary ones. In fact, a few universities’ requirements to enter medical school were less than their requirements to enter the academic colleges. The budgets of many university affiliated medical departments were disproportionately less than the budgets of other departments. Some uni- versities had such superficial connections with their medical departments that they not only did not support them, but they did not control them. Some schools, particularly endowed institutions, in effect merely “loaned” their names to propri- etary medical schools.
During this late 19th century period of rapid medical school development, Mississippi’s first medical school was established. “Kirk’s Clinical Institute of Medicine and Surgery” was issued a grant of charter by the state of Mississippi on April 27, 1882, with corporate domicile at Me- ridian. The corporation name was changed to “Meridian Medical College” on Aug. 4, 1884. There is no record of how long this school oper- ated, if it operated at all. The list of existing and extinct medical colleges in the United States pub- lished in the Aug. 16, 1919, Journal of the Ameri- can Medical Association does not mention it. The records of the AMA Council on Medical Educa- tion and Hospitals hold no information on the Meridian Medical College, and there is no record in the Mississippi Department of State of what disposition was made of the grant of charter.
The need for formal, university controlled med- ical education in Mississippi was recognized long before it became a reality. As early as 1870-71 the Board of Trustees of the University of Mississippi, under the chancellorship of Dr. John Newton Waddel, passed a resolution citing this need. The board further specified that the University’s med- ical department should be patterned after “the plan in the University of Virginia, which has proved to be so eminently successful, just as soon as resources of this institution shall have increased to a sufficient amount to admit it.” An announce- ment to this effect was carried in the University of Mississippi catalogues from 1870-79. Because no provision was made for a medical department’s establishment, this announcement was dropped from the catalogues published after 1879.
REASONS FOR DELAY
There are several reasons why a medical de- partment was not established during this period. First, the board’s interest may have been more apparent than real, for it came at a time when it was considering a change from the close college system to a university system. Second, the problem of available finances undoubtedly entered the pic- ture. Third, opponents of the medical department argued that a small town such as Oxford was in- adequate for a medical school, primarily because it lacked necessary hospital facilities and because it could not supply adequate numbers of human bodies for dissection. Proponents, however, cited such towns as Charlottesville, Va., and Ann Ar- bor, Mich., as being no more adequate than Ox- ford but with medical schools located within their limits. Nevertheless, no positive action was taken during this period.
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The next mention of a medical department was made in the 1894-95 session catalogue. At this time the University had only two departments:
( 1 ) the department of science, literature and arts, made up of 25 schools and (2) the department of professional education, made up of only one school, the school of law, established in 1854. The brief announcement, carried under the heading of the department of professional education, read: “It is hoped that in the near future the University will be able to establish schools of medicine, of pharmacy, and of engineering/' By this time, Dr. Robert Burwell Fulton had been named chancellor of the University, succeeding Dr. Edward Mayes in 1892. On June 20, 1899, Dr. Waller S. Leathers was elected to the University faculty as assistant professor of natural history and geology. Whether or not his appointment was made with an eye toward establishing a medical school is not definitely known. Nevertheless, it proved to be a step in that direction. He and Chancellor Fulton soon began formulating plans for a medical de- partment. It has been reported that Chancellor Fulton’s interest in establishing a medical school at the University grew out of a suggestion made to him by Dr. Peter Rowland, then president of the Mississippi State Medical Association.
FINANCIAL PROBLEMS
These early medical school advocates faced the problem of securing finances. They argued to the Legislature and the University’s Board of Trustees that Mississippi was one of the few older states with no medical education system. They admitted that there was little demand for more mediocre medical schools, but pointed out that there was a real need for superior institutions.
The fact that the University already taught many courses of the first two years was an eco- nomic advantage, as the school already owned much of the needed equipment. Another strong argument was the approximately 350 students who left the state every year for medical education, carrying at least $80,000 to other colleges. It was also argued that a medical school would create a stronger and more influential medical profession in the state. The arguments for a medical school were summed up in the chancellor’s statement to the Legislature: “The need for a well-equipped medical school in the state is as definite as the need for well-trained physicians and surgeons.”
On June 1, 1903, the Board of Trustees passed a resolution organizing the medical department of the University of Mississippi. The medical depart- ment was to offer the first two years of the course
in medicine. Less than one month prior to this action, on May 5, 1903, the Association of Ameri- can Medical Colleges, meeting in New Orleans, had adopted a resolution giving full recognition to medical schools offering only the first two years in medicine, terming them “medical schools which do not give diplomas.” Although the precedence of two year schools had been set by such colleges as the University of Kansas and the University of North Carolina, the AAMC’s action probably in- fluenced the establishment of the Mississippi two year school.
A NEW VIEWPOINT
Despite the recognized need for a formal uni- versity-controlled medical education program, many Mississippi physicians opposed the two year school maintaining that a large city was necessary for medical teaching. Lortunately, how- ever, radical changes in the best U. S. medical schools were occurring due to a growing advoca- tion of separate teaching of scientific and clinical medicine. Many educators pointed out the dis- advantages inherent in allowing students to attend clinics before they had the basic medical sciences. They argued that such practices frequently result- ed in the students becoming so involved in clinical material that they lost interest in the study of the basic science material.
The proponents of a Mississippi medical school were most interested in this new educational view- point. They became convinced that the two year school was in accordance with modern methods of instruction, but that it should be begun with the understanding that the last two years would be added when the University could secure a hospital in which the clinical branches could be properly taught. A number of other advantages to the stu- dents were also pointed out, including such things as small classes, two years’ association with men who were masters in their fields, special personal attention when needed or desired, opportunity of witnessing various demonstrations, and the advan- tage of a university environment.
The medical school of the University of Missis- sippi opened for its first session on Sept. 17, 1903, becoming the second school in the department of professional education, and the 27th school in the University. Sixteen students were registered for this first session which was scheduled for nine months and divided into three terms of three months each. The first faculty, including both ad- ministrative and teaching personnel, included 16 or 17 members.
( Part 11 will appear in the February, 1961 , is- sue of Journal MSMA.) ***
1190 North State Street
JANUARY 1961
17
What
to Do About Adoptk
Lawyer.
In the late 1800’s adoption was a pretty casual affair. Trainloads of children from large eastern orphanages would tour through the Midwest stop- ping at every large town. The children would line up on the high depot platform forming a single line according to height, and local citizens would simply point out the girl or boy they wanted. The unchosen children would then climb back on the train and travel on to the next stop.
Adoption procedure has changed quite a bit since those days. For one thing, it is estimated that in the United States there are approximately 18 couples who have made formal application for adoption for every child available. This increase of demand over supply has made possible greater protection of the adoptive children.
One agency which has been continuously con- cerned with adoption procedure is the U. S. Chil- dren’s Bureau. Dr. Howard Nelson, secretary- treasurer of Delta Medical Society and a member of AMA’s Committee on Maternal and Child Care, attended the May 1960, meeting on adoptions called by the Children’s Bureau.
The meeting, which was held in Washington,
18
J sli
Doctor,
:ial Worker View Their Roles
D. C., was planned in order to develop better un- derstanding among the doctor, the lawyer, and the social worker in the areas of adoptions and serv- ices to unmarried mothers. The group concluded that local programs outlining the professions’ re- sponsibilities in adoption procedures would con- tribute to a greater mutual understanding.
As a direct outgrowth of the Washington meet- ing, the Delta Medical Society included a panel on adoptions on the scientific program for its Oct. 12, 1960, meeting. On the panel. Dr. Nelson presented medicine’s responsibility. Norman C. Brewer, Jr., * attorney at law of Greenwood, discussed the legal § aspects of adoption. The social work field was § represented by James R. Stokes, program director ° of the Foster Care Section, State Department of S Welfare. u
Journal MSMA is happy to publish the con- clusions of this panel — which may well be the first of its kind to appear on the scientific program of a medical organization. £
(Artwork is by James M. Goodman, Director £
of Art, Department of Surgery, University of %
Mississippi School of Medicine.) j
WHAT TO DO ABOUT ADOPTION?
The Physician’s Role Is Purely Medical
HOWARD A. NELSON, M.D.
Greenwood, Mississippi
Adoption has existed from time immemorial. It was practiced by the ancient Egyptians, Baby- lonians, Assyrians, Greeks, and Romans, usually for the purpose of acquiring an heir or successor. Reference is also made to it in the Bible. Moses was adopted by the Pharaoh’s daughter and Mor- decai took Esther for his own daughter. Adoption originally was a voluntary arrangement between the adoptive parent and the child, made when the child was old enough to decide if he wished a new setting.
Adoption, as practiced in the United States, means the severing of the rights and responsibilities of the natural parents of the child and the crea- tion of new legal ties for both the child and adop- tive parents.
The role of adoption in the life of the com- munity is obviously important and of great con- cern to all citizens. The regular adoption process serves the child, the natural parents, and the com- munity, in that order. Each adoptive placement directly involves one or two natural parents, two adoptive parents, and several professional persons. Because of the complexity of the procedure, it requires the coordinated efforts of the social workers, the physicians, and the lawyers. Repre- sentatives of other professions, e.g. psychologists, clergymen, anthropologists, and geneticists, are often needed as well. Certainly the importance of providing a good family setting for a child and the magnitude of the total adoption process command our interest both as citizens and doctors of med- icine.
Experience has uncovered many gaps in the knowledge of the social, medical, and legal aspects of adoption. This has suggested the need for ex-
Secretary-Treasurer, Delta Medical Society, and member,
Committee on Maternal and Child Care, American
Medical Association.
tensive research and for revision of many older practices and laws. The need for legislation which will provide legal safeguards for all concerned in adoptions is of primary importance. It is not realistic to believe that any one person, whatever his interest, capabilities, and profession, can ade- quately conduct this entire procedure alone.
The physician has both direct and indirect re- sponsibilities in adoption. The direct responsibil- ities concern services to the three parties involved — the natural parents, the child, and the prospec- tive adoptive couple. The indirect responsibilities are those rendered as a consultant to, or as a member of, a social agency practicing adoption, as a member of a hospital staff, as an educator, and as a citizen.
The doctor, whether he be the family physician or obstetrician, is frequently the first person to become aware of an impending adoption. He diag- noses or corroborates the suspected state of preg- nancy. He renders antepartum care, delivers the child, and gives postpartum care and such other medical service as is indicated. He should refer the mother to an appropriate social agency where she may receive help for her baby as well as her- self.
The health of the adoptive parents is the con- cern of the physician and should be free from any seriously incapacitating disease so that they will be able to fulfill the usual parental role. If an in- fant is accepted into a family group, he should have a mother and father who are able to look after his needs, who can participate in many of his activities, and who have a reasonably good ex- pectancy of being with the child until he attains maturity.
In addition to providing medical care, the phy- sician is often placed in the position of counselor
( Turn to page 24)
t 20
JOURNAL MSMA
WHAT TO DO ABOUT ADOPTION?
Law Protects Adoptive Child and Parents
NORMAN C. BREWER, JR., LL.B.
Greenwood, Mississippi
The Mississippi Legislature in the Extraordi- nary Session of 1955 enacted into law what is now known as “The Adoption Law of the State of Mis- sissippi,” as set forth in Chapter 34 of the Laws of 1955 of the State of Mississippi and being Sec- tions 1269-02 through 1269-13 of the Mississippi Code of 1942, Recompiled, as amended.
This new adoption law enacted by the Missis- sippi Legislature was a far-reaching legislative en- deavor and has served to strengthen the adoption laws of Mississippi. To protect not only the adop- tive parents but the adopted children, the court procedures for the adoption of children have been removed from the prying eyes of the public and the court records have been made unavailable to all except the officers of the court.
The adoption law of Mississippi provides that any person may be adopted in accordance with the provisions of the act, in term time or in vaca- tion, by an unmarried adult or by a married per- son whose spouse joins in the petition, provided that the petitioner or petitioners have resided in this state for 90 days preceding the filing of the petition, unless the petitioner or petitioners, or one of them, be related to the child within the third degree according to the civil law, in which case such restriction shall not apply. Such adop- tion shall be only by sworn petition filed in the Chancery Court of the county in which the adopt- ing petitioner or petitioners reside and in which the child to be adopted resides, or was born, or was found when he was abandoned or deserted, or in which the home is located, to which the child shall have been surrendered by a person author- ized so to do.
Chairman, Board of Bar Admissions, Mississippi State Bar, 1959-60.
An innovation in the new law provides for two things. First it requires a doctor’s certificate show- ing the physical and mental condition of the child proposed to be adopted. This certificate of the doctor must be attached to and made a part of the original petition filed in the court. Secondly, at- tached to and forming a part of the petition must be a sworn statement of all property, if any, owned by the child. In other words, before a child can be adopted under the laws of Mississippi, a bona fide, qualified doctor must examine the child and certify to the court that the child is in good physical and mental condition and is a fit subject for adoption. If the adopted child has property, then a sworn affidavit must be attached to the petition, showing exactly what property the child possesses at the time it is adopted.
The new adoption law goes further and requires the joinder of natural parent or parents in the adoption proceedings. The natural parent or par- ents can come in in one of two ways. They can either come in voluntarily or they can be sum- moned by legal process. If they come in volun- tarily, they simply file a consent to the adoption proposed in the petition and the law requires that the consent shall be duly sworn to or acknowl- edged and executed only by the following persons:
(1) the parents or parent, if only one parent,
(2) in the event both parents are dead, then any two adult kin of the child, within the third degree, computed according to the civil law, or (3) the guardian ad litem of an abandoned child, upon petition showing that the names of the parents of such child are unknown after diligent search and inquiry by the petitioners.
There is one important feature of the new adoption law that I think is particularly worthy of
(Turn to page 25)
JANUARY 1961
21
WHAT TO DO ABOUT ADOPTION?
Social
Worker Serves as Coordinator
In discussing the responsibility of the social work- er in adoption, I will use the definition of adoption as a way of establishing new families for some children.
One cannot discuss the responsibility of the social worker without first speaking briefly of the nucleus which gives the social worker his respon- sibility. This nucleus in nearly all cases is some type social agency providing a structure within the community in which the social worker may use his skills and resources to meet the needs of the various individuals involved in the adoption.
Creation of the family through adoption is not the usual way of having a family. Relinquishment of a child to another family for rearing is unusual and often a painful process. Since the child is be- coming a part of a family that is not his own, protections are needed to safeguard him, his natural parents, and his new adopted parents. The accumulated knowledge and experience of the agency and of the social worker, and the social worker’s skill are important tools in helping all parties involved in these unusual processes. In recent years social agencies have come to accept the principle that most children who like a per- manent plan can be adopted and families must be found for them. The important consideration is that a child needs a family to whom he can be- long. While adoption is one way of finding new homes for some children born out of wedlock, it does not meet all the problems growing out of illegitimacy.
Someone has said that the agency focuses on a family for each child rather than on a child for each family. Placement of children and working with their parents are part of the specific respon-
Program Director, Foster Care Section, Mississippi State Department of Public Welfare.
JAMES R. STOKES, M.A.S.A.
Jackson, Mississippi
sibilities of the child welfare worker. The store of knowledge gained through repeated experience in working with parents and children is an asset not only to the individual worker but to the profession itself and to other professions.
Another asset of the social agency is the factor of its accountability to the community for what it does or does not do. In one way or the other, adoptions involve the total community. Agencies are authorized to perform their functions and these functions are regulated and controlled. The public is involved in the establishment of agency policy and agencies are accountable to the public. This is not true of an individual involved in an independent adoption.
Confidentiality is an important problem in all phases of the adoption process. The social agency has a particular responsibility to preserve the anonymity of natural and adopted parents in order to offer permanent protection to the child. Records and other important material that will safeguard the child’s identity must be preserved.
Another aspect of the social agency’s contribu- tions to the adoption process is that the agency responsibility continues for as long or as short a time as the situation demands it. It does not ter- minate with placement of a child in an adoptive home but continues until the adoption has been approved by the court and many times even longer.
We agree, however, that social agencies have an obligation to hold together the unique skills and contributions of other professions — particu- larly medicine, law, and religion — and to use them in meeting the needs of the child, the natural par- ents, and the adopted parents. In addition to us- ing knowledge of the medicine and the law, the social agency may also require consultation with psychologists, geneticists, anthropologists, and sociologists.
22
JOURNAL MSM A
The social worker as an individual also brings into adoption a uniqueness seldom found in other professions. One of the more respected traits of our profession includes knowledge and under- standing of human behavior and the techniques that help individuals in their social adjustments. In adoption, the social worker helps the various parties — the child, the natural parents, and the adoptive parents — clarify for themselves what they are doing and what they want to do, and gives each of them support until a satisfactory solution has been reached. In this process the total situa- tion is considered and choice is given and respon- sibility taken when this seems to be indicated.
The social worker within the agency setting carries responsibility in adoption to three interre- lated groups of people. First of all, the social worker carries a responsibility to the natural par- ents of the child. The social worker with her unique skills can often help these parents arrive at a plan for their child and for themselves that will represent a lasting decision for them and one in which they can have confidence.
THE UNMARRIED MOTHER
The unmarried mother is often in a vulnerable position in our society. If she is to have the safe- guards she requires, she must be offered practical service and coordinations for her care and pro- tection during pregnancy. This may be medical care, financial help, shelter care, on legal advice. Perhaps most important of all, she needs the kind of continuous relationship with the social worker that will enable her to make an early decision for her child both for the child’s sake and her own. It cannot be overlooked that adequate planning must take place for the unmarried mother as well as for the child whom she may surrender. Without some understanding of herself, she may become immobilized. I think we can all readily agree that an unmarried mother comes to us laden with emotional ties. With the severance of these emo- tional ties, a deep understanding, and skillful handling, not only the mother but the child is less likely to be damaged. Once the decision is made, the social worker must stand by to help the natural parents in carrying out suitable plans. The important aspect of this whole process is that the future as well as the present is taken into con- sideration.
The second person with whom the child welfare worker must deal is the child. Before an adoptive plan can be considered, a decision must be made as to whether or not a permanent separation from the natural parents will meet the child's needs. In meeting this responsibility, the agency and the
social worker put into focus finding a family for the child rather than a child for the family. The social worker must have a knowledge of the basic needs of all children, and she must be able to determine the special needs of each child. Using this information, the social worker and the agency try to choose insofar as possible a family that ap- pears to have the special qualities that will make it possible for the child to develop his potentials for growth.
FOSTER HOMES
The social worker and the agency also must have on hand for immediate use a number of homes available to give good care to children dur- ing the time the permanent plans are in process. The agency also must have access to these homes in case the child needs further study or is unadopt- able. Permanent plans for the child should be made at the earliest possible time. As an assurance to the adoptive family, however, early plans for placement of the child can be made only when a great deal is known about the background of the child’s natural parents. Here the social worker be- comes an invaluable tool in planning for a pro- spective adoption.
Many times legal entanglements exist that in- terfere with the child’s being released for adoption. Here is the time the agency seeks competent legal counsel so that diffculties may be resolved when- ever possible.
Even after a child has been placed into an adoptive home, he may need direct or indirect help from the social worker. The social worker is also responsible for helping adoptive parents in un- derstanding the child's reaction to change or their own feelings about him. Such help to these new parents gives both the child and his parents better security.
ADOPTIVE PARENTS
v.
Adoptive parents compose the third group to which the social worker contributes. His work with them has a direct bearing on the success or failure of the adoption.
One of the problems complicating the whole adoptive process is the difference between the sup- ply and demand for white infants. Childlessness plus a desire to adopt a child do not in themselves mean that a couple will make good adoptive par- ents.
The social worker’s understanding of human behavior equips him to make an evaluation of the applicants. The adoptive parents must have good health, a stable marriage, exhibit a degree of ma- turity, and have evidence of some ability to adjust
JANUARY 1961
23
SOCIAL WORKER / Stokes
to the reality of their childlessness. They must be able to see the child as a human being with his own personality who will need love and affection and a sense of belonging. While the adoptive parents will get great satisfaction from nuturing, stimulat- ing, and encouraging the child, the primary goal in their care of the child is to help and love him for his own sake. They should be people who are warm, flexible, understanding, and who have a desire to help a child develop his potentialities.
FACTORS IN ADOPTION
The social worker helps adoptive applicants with an understanding of what is involved in adop- tion and whether or not adoption will meet their needs. Both the husband and wife must wish to adopt a child, and the worker has the responsi- bility of determining that they both wish to do so.
After a home has been approved and a child tentatively selected for it, the social worker gives the adoptive parents information about the child’s background, his special needs, and his potentials, and helps to decide whether or not this is the child they want. The worker also plans for the actual placement of the child and helps the child and his adoptive parents prepare for it.
POST-PLACEMENT HELP
After placement of a child, the worker gives the adoptive parents any assistance they require. The social worker recognizes that factors exist in adoption placement that are not inherent in normal parenthood. They will do everything they can to help adoptive parents cement their relationship with the child.
Again accurate record keeping and a respon- sibility back to the community enter the picture with adoptive parents.
MEDICINE’S IMPORTANCE OBVIOUS
Throughout this paper, I have purposely omit- ted the medical profession. The medical pro- fession is so intricately wound into adoption that its importance is obvious. Certainly services need to be given to the natural parents of the child, which in most instances means the unmarried mother. It is only with the understanding and medical skill of a warm, accepting physician that the unmarried mother can be aided to arrive at a decision concerning her child. It is also an abso- lute necessity that the child be in the hands of a competent physician. From the time it is delivered to his adoption, the physician indirectly guides
the agency and the social worker in making ade- quate plans for this child. The understanding and skill of the physician again plays a very definite part with the adoptive couple. Sterility is not an easy thing to recognize or accept. Again the phy- sician takes on the robe of a social worker in help- ing adoptive parents accept the situation of ste- rility. Throughout the adoptive placement the phy- sician plays an integral and vital role in helping cement the relationship between the adoptive parent and child.
Certainly without the assistance of the medical profession, the social worker profession would not be able to operate in adoption or any other phase of its responsibilities. ***
5650 Brentwood
PHYSICIAN’S ROLE / Nelson
to the unmarried pregnant woman as well as to the prospective adoptive parents.
The doctor is best equipped to provide diag- nostic appraisal and medical care during the new- born period in the hospital and thereafter in the home of the natural parents or in the foster home. He is called upon to treat, to evaluate, and to interpret the handicaps of children who are being considered for adoption.
The physician who diagnoses pregnancy in an unmarried woman is in a particularly advantageous position to refer her to an appropriate agency for counseling and aid of whatever type may be re- quired. Similarly, he often refers childless couples to agencies where they can apply for a child for adoption.
MEDICAL INFORMATION
The physician may serve as a consultant to a social agency. He advises as to the health and de- velopment of the infant, the medical background of the natural parents, and the physical status of the adoptive parents. He must be willing and able to interpret the prognosis of persons with chronic disease.
The physician should participate in establishing hospital policies which insure adequate medical care for the unmarried pregnant mother and her child. This requires social services as well as ante- partum, obstetrical, and postpartum care. Some hospital staffs, for example, have instituted pol- icies which require that social service consultation must be offered to the mother before her infant can be placed for adoption.
The mere mention of child adoption always evokes a warm emotion and a feeling of thankful- ness in all parents of adopted children. The real
24
JOURNAL MSM A
concern in this procedure today is in those cases in which the adoption is not arranged through an authorized agency.
EVALUATION OF CHILD
The role of the physician in adoptions should be a medical one only. He is not a social worker, nor should he try to substitute for the legally con- stituted authorities in this important function. The physician is essential only because he can give ad- vice on matters of health, growth, and develop- ment, genetic influences relating to the infant, and the natural mother’s prenatal care. The details of the birth and medical and developmental records on the infant are all extremely important factors in the final decision as to placement. Few, if any, human beings are perfect specimens. This applies for babies up for adoption.
Since each individual in our society has dignity and worth, the purpose of all efforts toward pro- tecting children in adoption is to insure for each child the best possible opportunity to fulfill his greatest potentialities as a human being.
308 Fulton Street
LAW’S PROTECTION / Brewer
note and that is the fact that in the case of a child born out of wedlock, the father shall not be deemed to be a parent for the purposes of the act and no reference shall be made to the illegitimacy of such child. The new law sets out in detail the exact steps that are required to be taken in the case of the adoption of a child, from the filing of the petition through to the entry of a final decree. The law says that a final decree of adoption shall not be entered before the expiration of six months from the entry of the interlocutory decree, except where the child is a stepchild of a petitioner or is related by blood to petitioner within the third de- gree according to the rules of the civil law, or, in any case in which the chancellor, in the exercise of his discretion, shall determine from the pro- ceedings and evidence in such cause that the said six months’ waiting period is not necessary or re- quired for the benefit of the court, the petitioners, or the child to be adopted.
It occurs to me that physicians would be inter- ested in knowing exactly what a final decree of adoption actually adjudicates. After all the re- quirements of the act have been fully met and the chancellor is satisfied that the adoption is the best thing for the adoptive parents and the child proposed to be adopted, there is entered a final decree. This decree adjudicates the following:
(1) That the child inherit from the and through the adopting parents and shall, likewise, inherit from the other children of the adopting parents, to the same extent and under the same conditions as pro- vided for the inheritance between brothers and sis- ters of the full blood, by the laws of descent and dis- tribution of the State of Mississippi, and that the adopting parents and their other children shall in- herit from the child just as if the child had been born to the adopting parents in lawful wedlock.
(2) The child and the adopting parents and adop- tive kindred are vested with all the rights, powers, duties and obligations, respectively, as if such child had been born to the adopting parents in lawful wedlock, including all rights existing by virtue of the laws of Mississippi.
(3) That the name of the child shall be changed, if desired.
(4) That the natural parents and natural kindred of the child shall not inherit by or through the child, except as to a natural parent who is the spouse of the adopting parent, and all parental rights of the natural parents or parent shall be terminated, except as to a natural parent who is the spouse of the adopt- ing parent.
It is interesting to note that there is nothing in the act which restricts in any way the right of any person to dispose of property under a last will and testament and, while the adoption statute sets forth all rights of inheritance between the adoptive par- ents and the adopted child and the relations of both, there is nothing that prohibits an adult from making a will that disposes of his property ac- cording to his own wishes.
REVISION OF CERTIFICATES
After the final decree of adoption is entered, a certified copy of the final decree is furnished to the Bureau of Vital Statistics, together with a certificate which has been signed by the clerk of the court giving the true or original name and the place and date of the birth of the child. There- upon, the bureau prepares a revised birth certifi- cate which contains the original date of birth with the place of birth being shown as the residence of the parents at the time the child was born, but with the names of the adopting parents and the new name of the child. It is also noted that the fact that a revised birth certificate is issued shall be indicated only by code numbers or some letter inconspicuously placed upon the face of the certifi- cate. The word “revised” shall not appear and does not appear upon the revised birth certificate. The original birth certificate is then removed and placed with the certified decree of adoption and the certificate in a safety lock drawer or vault and the same are not public records and shall not be divulged except upon the order of the court render-
JANUARY 1961
25
LAW’S PROTECTION / Brewer
ing said final decree. To all intents and purposes, the revised certificate shall be, and it is, the birth certificate of the child.
The new act does everything it is humanly possi- ble to do to protect the adopted child. For example, no reference is required to be made as to the marital status of the natural parents of the child, nor shall any allegation or recital be made therein that the child was born out of wedlock in any petition filed or any decree entered upon such petition. In the decree reference to the child is made by the name conferred upon it by the court, rather than by its original name, if the name of the child has been changed. The style of the cause and the docket entry thereof shall recite only the names of the petitioners and that the case is for the adoption of a child described in the petition.
In addition to this, all proceedings under the act are held to be confidential and shall be held in closed court without admittance of any persons other than interested parties, except upon the order of the court, and all the reports and files and records pertaining to adoption proceedings are confidential and shall not be considered public
records under the law. They are withheld from inspection or examination by any person except upon the order of the court in which the proceed- ing was had or good cause shown. This does not mean that officers of the court, such as attorneys, are not given access to such records, upon request. The law provides that a separate adoption docket be kept by the chancery clerk and a separate min- ute book on adoption proceedings, both of which are kept under lock and key at all times and are not available to the public scrutiny.
If we may sum up in few words the intent, pur- poses, and effect of the Adoption Law of the State of Mississippi, we might say that every effort has been made to take away from adoptions any stigma of disgrace and to make the proceedings as secret as possible so that when the adoption is concluded, the adoptive parents and the adopted- child are placed in the same status as natural parents and the children born in wedlock to these natural parents. The protection afforded by the new adoption law of Mississippi is a double one in that it protects not only the adopted child, but it protects the adoptive parents. ***
107 West Market Street
ONE FOR THE MONEY
Calling for more Federal funds for medical research and educa- tion, Dr. Leo G. Rigler, executive director of the Cedars of Lebanon Hospital, Los Angeles, anticipated the question “why Federal rather than private or local funds?”
Paraphrasing Willie Sutton’s famous reason for robbing banks (“that’s where the money is”), Dr. Rigler said: “Like it or not, with our present tax system, our Federal government is where the money is.”
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JOURNAL MSM A
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
Volume II, Number 1 January 1961
‘Volume II, Number V
Journal MSMA, 1960’s fledging of paper, ink, and an idea, observes its first birthday with this issue. Whether it earned its freshman grades or not is something for its faculty of readers to say. This much, however, is apparent: The Journal has been accorded a warm and generous reception in the distinguished company of the American scientific press. Its growth belies its youth, some- thing aided, not in the least, by contributions from able authors and substantial advertising from those who recognize its importance as an ethical com- munications medium.
There is no secret success formula for building a new scientific publication other than rigorous application of the old saw of 10 per cent inspira- tion and 90 per cent perspiration. Journal MSMA was begun as a team activity and remains such today. Each issue represents hundreds of work hours by dozens of individuals. What begins with the distinguished author of international repute must be carried through the unbelievable complex of scientific journalism to the skilled technician at the printer’s stone.
In volume one, number one, it was stated edi- torially that the Journal “. . . is not now nor will it ever be faultless but its mightest effort will be to rise to usefulness and to overcome mistakes and undoing.” This is reaffirmed with renewed pur- pose. The Board of Trustees under whose super- vision the Journal is published, the Committee on Publications, the editors, and staff ask all read- ers for their counsel, constructive criticism, and
comment. Their total aim is to fulfill the assigned mission of providing a scientific and socioeco- nomic vehicle especially adapted to the needs of the association, a reliable and authoritative com- munications medium among the membership con- taining a sufficient variety of presentations and information to achieve wide usefulness. At the same time, the Journal team recognizes that the publication cannot and should not be all things for all purposes.
To these objectives of service this second vol- ume is dedicated. To every reader and contributor go the appreciation of those charged with produc- ing the Journal. To achieve usefulness, journal- istic character, and integrity reflecting the associa- tion’s 104 years of service is and will be the Jour- nal’s quest. — L.W.L.
The Lost Doctors
The intense competition that prevails for talent among the various industries and businesses is creating a serious situation for our own profession. Deans of medical schools are deeply concerned about the decrease in applications for entrance from the top level students. For the last three to five years the number of “A” students that have applied to medical schools has dropped and selec- tions have been made from a larger proportion of “B” students and lower. This is a new experience
JANUARY 1961
27
EDITORIALS / Continued
for medical schools, because there have always been an adequate number of these top level stu- dents to select. In order to assure a continuation of the high standards of medicine in this country, we cannot lose the best students to other profes- sions.
It seems that the reason for this is that we are being out-recruited by representatives from the other fields. The technological age of the last half of our century is demanding a more educated, a more highly intelligent person. The rewards of- fered by these various professions often appear more enticing and more challenging than those to be gained in medicine. The appeal to our youth is being made on the basis of the possibili- ties of adventure and service. We are living in a highly imaginative age. The fantasy of the pre- vious generation is the reality of today. As our world shrinks, and the far away place and person of yesterday is now a close neighbor, we find ourselves moving into an area where human un- derstanding and a life of service is more necessary than ever before. It is on this basis that fields such as electronics, chemistry, nuclear physics, and mathematics are appealing to our youth. They are offering more than material rewards. They are offering an opportunity to be creative and imagi- native— an opportunity to have a personal hand in the far reaching contributions to humanity.
Of course medicine has always had this appeal. We need to renew this challenge. We must dust off the pedestal of medicine so that once again it will loom as a shining platform, as it has in the past, to which every boy and girl aspires. Per- haps we have been resting too much on the laurels of the past so as to give the mistaken impression that there is no more future to medicine. In reality, the challenge of medicine is greater today than it has ever been. In the years ahead, the point we have reached at this time will seem as primitive to the physicians of tomorrow as the days of Pasteur and Koch seem to us today. We must re- new the symbol of the man in the white coat and re-establish the nobility of medicine as a profes- sion.
The profession of medicine is closer to human- ity than any other. The challenge of medicine is more far-reaching than in any other field. The need for the highest type individual is therefore greater than it is in any other profession. When we can once again establish this appeal, we will not be out-recruited any longer. In fact, to sur- vive we must not permit this situation to continue. — T. J. M.
Sirs: The president’s page, “Interpret, Please,” in the Journal of the Mississippi Medical Asso- ciation for November 1960 has been read with interest by members of our staff. It is gratifying to us that you have considered it important to bring this timely discussion of drugs and the pharma- ceutical industry to your many readers.
Robert J. Benford, M.D. Director of Medical Relations Pharmaceutical Manufacturers Association Washington. D. C.
The following physicians have been elected to membership by their respective component medi- cal societies in the Mississippi State Medical As- sociation and the American Medical Association:
Booth, William Harper, Jr., Lambert. Born Maben, Miss., Oct. 12, 1929; M.D., University of Tennessee School of Medicine, Memphis, 1956; interned Baroness Erlanger Hospital, Chatta- nooga, Tenn.; otolaryngology residency, Universi- ty of Tennessee, Memphis, one year; Lieutenant, U. S. Naval Reserve, two years; elected Nov. 9, 1960, by Clarksdale and Six Counties Medical Society.
Johnson, Whitman Benedict, Jr., Clarksdale. Born Clarksdale, Miss., Dec. 2, 1928; M.D., Uni- versity of Pennsylvania School of Medicine, Phil- adelphia, 1955; interned Baptist Memorial Hos- pital, Memphis, Tenn.; surgery residency, Baptist Memorial Hospital, Memphis, four years; elected Nov. 9, 1960, by Clarksdale and Six Counties Medical Society.
Whitehead, Thomas Bennett, Ellisville. Bom Hattiesburg, Miss., Dec. 19, 1931; M.D., Univer- sity of Tennessee School of Medicine, Memphis, 1957; interned Mobile General Hospital, Mobile, Ala.; general practice residency, South Mississippi Charity Hospital, Laurel, one year; Corporal U. S. Navy, two years; elected Sept. 11, 1960, by South Mississippi Medical Society.
28
JOURNAL MSMA
Book Reviews
The Management of Fractures and Soft Tis- sue Injuries. By the Committee on Trauma, Amer- ican College of Surgeons. Illustrated with 372 pages. Philadelphia-London: W. B. Saunders Company, I960. $5.00.
As the title indicates, this is a combination of two books that have been published separately in the past but are now combined with the outline on fracture treatment being followed by outline on early care of soft tissue injuries. This two-in- one edition causes much duplication of material as each book in the past contained chapters on the care of head injury, spinal column injury, neck injury, and facial injury. In addition, each section give considerable detail about x-ray posi- tions and techniques which are tedious as well as duplicated. Each chapter attempts to be autono- mous and this leads to repetition.
The book is simply and clearly written and is easy to understand, but it contains very few il- lustrations although the index and bibliography are ample. There is little room for disagreement with the principles set out in the book except perhaps those in the care of the head and spinal cord injuries, and I realize that these are still controversial subjects. I found that the chapters on care of shock, burns, and bites to be the most informative and interesting.
I would only recommend this book for students, interns or other very young medical practitioners.
Jack H. Phillips, M.D.
Outline of Pathology. By John H. Manhold, Jr., D.M.D., and Theodore E. Bolden, D.D.S. 340 pages. Philadelphia-London: W. B. Saunders Company, I960. $4.75.
In the preface, the authors state that this book has been written to interest medical and dental students, interns, residents, and general practition- ers. It was felt that these individuals in searching for specific material usually found that the stand- ard pathology text gave much more than needed whereas, the available abridged versions were usually too incomplete.
They state that their intent has been to set
forth “a complete outline of subject matter of pathology so as to serve ( 1 ) the student as a basis for study, and (2) the graduate as an adequate recall instrument.” This book fills the require- ments set down by the authors.
Students will disagree about the need for some conditions that have been included and some that have been omitted. This is an expected de- fect in any outline of this type. The arrangement of the book is standard, being divided into a sec- tion on general pathology and a section on sys- temic pathology. Many rather vague statements are made, but the authors expect that further study in a standard text will be necessary for more specific details.
For the medical or dental student, the out- line should be an adequate basis for study. For the general practitioner who has been out of touch with the field of pathology for some time, the outline of pathology of a specific organ should be valuable. For the advanced resident, and for the practicing physician who has had specialty training in any field, this outline should not be necessary.
C. B. Mitchell, Jr., M.D.
Domestic Journals
Medical Treatment of Endometriosis. Mason D. Andrews, Clin. Obst & Gynec. 3:492 (June) I960.
The author presents arguments for the desir- ability of developing a safe medical treatment of endometriosis in as much as many patients with this disease desire further childbearing, have symptoms which are disabling but not severe enough to warrant surgery, or present a poor risk for surgery. Since endometriosis produces disa- bility through the response of ectopic endometri- um to the normal hormonal cycle, the logical ther- apeutic agents to be used in medical treatment are hormones.
A review of the effects of estrogen therapy in various dosage schedules is given. This therapy is limited by side effects including breakthrough vaginal bleeding, excessive fluid retention, oc- casional severe uterine hemorrhage, and nausea and vomiting. The theoretical dangers of encour- aging the growth of endometrial carcinoma
JANUARY 1961
29
LITERATURE / Continued
through the action of unopposed estrogen is also stressed.
Androgen therapy is also discussed. The basis for the use of androgens lies in the ability of these agents to: 1. directly counteract the effect of es- trogen on ectopic endometrium and 2. suppress the pituitary in stimulation of endogenous estro- gen production. He suggests a trial of oral testos- terone for six weeks in a dosage of 10 milligrams per day. If improvement occurs, he repeats the course. The side effects of the use of androgens are masculinization, including hirsutism, acne, and clitoral hypertrophy. Increased libido is oc- casionally reported.
The availability of oral progestins has made possible a rational therapy based on the develop- ment of “pseudopregnancy.” Starting dosage of these agents is in the range of 10 milligrams per day with periodic increase of dosage to a maxi- mum of 40 milligrams per day. Therapy extends for 24 weeks. There were subjective and objective signs of improvement in 23 of 24 women. Im- provement was maintained after treatment in 22 of these women. Side effects of oral progesterones are in general the usual signs and symptoms of pregnancy. There was some nausea which was easily controlled. Breakthrough uterine bleeding was troublesome but could be managed by in- creasing the dosage. The major disadvantage of oral progesterone therapy is its present high cost. From subjective and objective evidence this ap- pears to be the most satisfactory medical form of treatment of this desease, although patients have not been followed for a sufficient length of time to assess the duration of improvement following treatment.
Lois M. Mosey, M.D.
The Monster Test. Edward Lehman, Arch. Gen. Psychiat. 3:335-344 (Nov.) I960.
Presenting proverbs to patients for explanation of their meaning has long been a method of get- ting information on ability to deal with abstrac- tions on a verbal level. In suspected cases of brain damage this function, among other things, may be important to test. Little, if anything, has been written of attempts to qualitatively assess such tests.
Dr. Lehman describes an interesting arrange- ment he has adopted on a qualitative basis and states the reason for his arrangement as well as his method of presenting the proverbs.
Arrangement: He presents the following four proverbs in the sequence given:
1. “Don’t cry over spilled milk.”
2. “Don’t judge a book by its cover.”
3. “When the cat’s away, the mice will play.”
4. “Two heads are better than one.”
Procedure: The proverb is given and the pa- tient asked “what does it mean?” If the patient’s response shows good ability to abstract the mean- ing, he is asked if he has heard it before. The re- sponse given is disregarded if he acknowledges having heard the saying previously. When his re- sponse is a concrete repetition of the surface meaning of the proverb, the examiner inquires, “Could it have a more general meaning?” In this manner the first three proverbs are presented and an idea of how the patient deals with abstractions is obtained. Then the last proverb is offered “Two heads are better than one.” This proverb deals not only with an abstraction which it contains, but also with the strength of the listener’s body image and capacity — at least in respect to the proverb’s subject matter — to soundly test reality.
The proverb may evoke a concept of two peo- ple or of two heads on a single body for example. The subject is given a pencil and paper and
“The doctor will see you just as soon as he finishes going over his morning mail.”
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JOURNAL MSM A
asked to “draw the two heads you picture in your mind when you think of the saying ‘two heads are better than one.’ ” Almost always a drawing can be obtained. If only heads are drawn the subject is urged to “draw the rest, below the heads.”
Interpretation of Results: Children under 10 and older mental defectives of IQ 50-70 may give no verbal responses but will give a drawn re- sponse. The responses are scored with a three or four letter sequence. Letter one may be K, L, M, N, or O (“Known already,” “Lone response,” “Monster response,” “Normal response,” “Zero response”) and they refer to the oral responses. The second letter may be as indicated above, but refer to the drawn response. Thus MM equals a verbal response of a monster and also a drawn monster. A third letter may indicate the type of monster (as S for Siamese or J for Janus or P for parasitic). The reader is referred to the ar- ticle itself for details of interpretation and re- cording.
The Results: The author states that there are significant differences between the psychotic, and neurotic, and the mentally deficient (as indicated above) on this test. The general rule was that normal responses are not evidence against psy- chosis, but with infrequent exceptions monster responses come only from psychotics. The author feels the test may sort out brain damage (or- ganic) from nonorganic cases. It is simple, con- sumes little time, and is easy to administer. It is summarized here because some physicians may wish to look up this interesting article and utilize the test in their practice.
Oscar E. Hubbard, M.D.
Robert Carlsey, Canton, was named medical representative of the Madison County Heart Council at the group’s November meeting. He will also serve as a community chairman.
Thomas Grover Cleveland, Meridian, was fea- tured as “Citizen of the Week” by the Meridian Leader on Dec. 1. Said the Leader: “Dr. Cleve- land is a member of the ‘old school’ of doctors and has been of great service to Meridian and the surrounding area during his tenure of service here.”
J. T. Davis, Corinth, won an honorable mention for his exhibit at the Southern Medical Associa- tion meeting held recently in St. Louis. Dr. Davis’s exhibit, entitled “Nerve Injuries of the Hand,” was one of approximately 60 exhibits from all sections of the United States.
James S. Fisackerly, Biloxi, has announced the opening of his offices. His practice will be limited to diseases of the eye, ear, nose, and throat. Dr. Fisackerly was retired July 31 from the USAF medical service after 26 years service. His last tour of duty was as commander of the USAF Hospital at Keesler.
Robert McBroome, Centreville, was elected chairman of the Wilkinson County Heart Council at the organizational meeting in November. C. E. Catchings, Woodville, will serve as medical ad- visor.
Dr. H. C. Ricks, Sr., Jackson, was featured as the “Pride of Northside” in the Nov. 10 issue of the Northside Reporter, Jackson neighborhood newspaper. Dr. Ricks is director of laboratories for the Mississippi State Board of Health.
Feemster, Lucien Carl, Jr., Tupelo.
M.D., University of Washington School of Medicine, Seattle, 1924; interned Washington Uni- versity Hospital, Seattle; Major, U. S. Army, four years; Fellow of the American College of Surgeons; member of AQA honorary scholastic medical fra- ternity and Southern Surgical Congress; died Nov. 13, 1960, aged 59.
Fugitt, Mabel Smith, Indianola. M.D., Meharry Medical College, Nashville, Tenn., 1914; founded St. Anthony’s Clinic, Memphis, Tenn.; died Oct. 25, 1960, aged 71.
Howard, Hector Holbrook, Jackson. M.D., Memphis Hospital Medical College, Tenn., 1910; postgraduate training at Vanderbilt University, Nashville, Tenn. and Tulane University, New Or- leans; died May 10, 1960, aged 86.
Trapp, Lee Howard, Monticello. M.D., Tulane University School of Medicine, New Orleans, 1949; interned Charity Hospital, New Orleans; past president of the staff of the Law- rence County Hospital; member of the American Academy of General Practice and Southern Medi- cal Association; died Nov. 8, 1960, aged 50.
JANUARY 1961
31
Coast Counties Medical Society, First Wednesday March, June, September, and November. Charles N. Floyd, 1412-23rd Ave., Gulfport, Secretary.
NATIONAL AND REGIONAL
American Medical Association, June 26-30, 1961, New York City. F. J. L. Blasingame, Executive Vice President, 535 N. Dearborn St., Chicago 10, 111.
American Academy of General Practice, April 13-20, 1961, Miami Beach, Florida. Mr. Mac F. Cahal, Executive Director, Volker at Brook- side, Kansas City 12, Mo.
American College of Surgeons, Sectional Meet- ing, January 16-18, 1961, Birmingham, Ala. Arthur I. Chenowith, Local Chairman, 2618 10th Ave. S., Birmingham, Ala.
Southern Society of Anesthesiologists, March 9- 11, 1961, Jackson. Curtis Caine, local arrange- ments committee, 4332 Manhattan Road, Jack- son.
Delta Medical Society, Second Wednesday April and October. Howard A. Nelson, 308 Fulton St., Greenwood, Secretary.
DeSoto County Medical Society, Second Thurs- day January, April, July, and October, 1:00 p.m., Hernando Motel Cafe, Hernando. L. L. Minor, Route 9, Memphis 9, Tenn., Secretary.
East Mississippi Medical Society, First Tuesday February, April, June, August, October, and December. A. Wayne Sullivan, 1204-2 1st Ave., Meridian, Secretary.
Homochitto Valley Medical Society, Fourth Tues- day Monthly, 7:30 p.m., Natchez Country Club, Natchez. W. T. Colbert, Natchez Gen- eral Hospital, Natchez, Secretary.
North Central District Medical Society, Second Wednesday March and September. W. A. Mid- dleton, 214 Summit St., Winona, Secretary.
STATE AND LOCAL
Mississippi State Medical Association, May 9-11, 1961, Biloxi. Mr. Rowland B. Kennedy, Exec- utive Secretary, 735 Riverside Drive, Jackson.
Mississippi Society of Internal Medicine, May 8, 1961, Biloxi. Frederick E. Tatum, Secretary, 707 Katie Ave., Hattiesburg.
Amite-Wilkinson Counties Medical Society, First Tuesday March, June, September, December. S. E. Field, Centreville, Secretary.
Central Medical Society, First Tuesday Month- ly, 6:30 p.m., Robert E. Lee Hotel, Jackson. George E. Gillespie, 5 14- A East Woodrow Wilson Drive, Jackson, Secretary.
Claiborne County Medical Society. D. M. Segrest, Port Gibson, Secretary.
Clarksdale and Six Counties Medical Society, Second Wednesday March and November, 2:00 p.m., Clarksdale. Robert R. McGee, 150 Yazoo Ave., Clarksdale, Secretary.
Northeast Mississippi Medical Society, Second Tuesday March, June, September, and Decem- ber, Tupelo. Eugene M. Murphey, III, 421 Main St., Tupelo, Secretary.
North Mississippi Medical Society, First Thurs- day January, April, and October, Oxford. R. L. Wyatt, Holly Springs, Secretary.
Pearl River County Medical Society, Second Mon- day March, June, September, and December. George B. Stewart, 139 Kirkwood St., Pica- yune, Secretary.
South Mississippi Medical Society, Second Thurs- day March, June, September, and December. Thomas F. Puckett, 715 Arledge St., Hatties- burg, Secretary.
Tri-County Medical Society, Second Tuesday March, June, September, and December. A. V. Beacham, Magnolia, Secretary.
West Mississippi Medical Society, Second Tues- day January, April, July, and October, 7:00 p.m., Old Southern Tea Room, Vicksburg. Tom H. Mitchell, The Street Clinic, Vicksburg, Secretary.
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JOURNAL MSM A
College of Surgeons Names King President-elect, Snelling to Presidency at November Meeting
Dr. Jack V. King, Jackson, was named presi- dent-elect of the Mississippi Chapter, American College of Surgeons, during the post-Thanksgiving 1960 annual meeting as Dr. M. M. Snelling, Gulf- port, assumed the presidency. Dr. G. Swink Hicks, Natchez, served as 1959-60 president, a dual gavel role running concurrently with the presi- dency of the Mississippi State Medical Associa- tion.
New officers of the Mississippi Chapter of the American College of Surgeons are, standing left to right, Dr. M. M. Snelling, incoming president; Dr. E. C. Hamilton, secretary-treasurer, and Dr. Jack King, president-elect. Dr. G. Swink Hicks, seated, is the outgoing president.
More than half the college’s 138 active Fellows attended the Jackson meeting to hear nine essay- ists during the day-long scientific session. Speakers included Dr. Harwell Wilson, Memphis, professor and chairman of the department of surgery, Uni- versity of Tennessee School of Medicine who pre-
sented “Personal Experience in Surgery of Tumors of the Liver.” Other featured essayists were Dr. H. G. Langford, Jackson, whose subject was “Hy- pertension Due to Renal Artery Occlusion,” and Dr. Warren N. A. Bell, Jackson, who spoke on “The Newer Chemotherapeutic Agents for Tumor Control.”
A scientific highlight was a panel presentation on “Complications of Surgery” over which Dr. Curtis P. Artz, Jackson, presided as moderator. Panelists included Drs. George F. Archer, Green- ville; Bedford F. Floyd, Gulfport; W. H. Parsons, Vicksburg; Leslie V. Rush, Meridian; and Harwell Wilson, Memphis.
The principal social occasion was an evening banquet with Dr. Hicks presiding. A guest panel presented a report of development of the new Pearl River Reservoir. Speakers included Mr. Eu- gene Thomas, chief engineer; Hon. Vaughn Wat- kins, chief counsel; and Dr. A. L. Gray, state health officer and a member of the reservoir com- mission. The evening was concluded with dancing.
Dr. E. C. Hamilton, Gulfport, was reelected secretary-treasurer for a three year term. The meeting was open to all MSMA members and scientific, business, and social sessions were held November 25 at the King Edward Hotel.
MHA Holds Workshops On Charity Regulations
The Mississippi Hospital Association held three December meetings to acquaint front office per- sonnel with the new rules and regulations govern- ing the hospital indigent care program.
Planned by the Council on Government Rela- tions, the workships were held regionally at Ox- ford, Columbia, and Jackson.
Charles W. Flynn, MHA executive director, and Robert G. Myers, secretary, State Hospital Commission, conducted the meetings. Lester Tuck is chairman of the Council on Government Rela- tions.
33
JANUARY 1961
MEDICAL ORGANIZATION / Continued
MSMA Officials Visit Congressmen
Officials of the Mississippi State Medical As- sociation visited the offices of every member of the state’s congressional delegation during the recent Washington AMA clinical session. Dr. G. Swink Hicks, MSMA president, said that “. . . a wide range of legislative topics were discussed during the meetings.”
MSMA leaders confer with Representative Arthur Winstead during the recent AMA clinical session at Washington. Shown in the Mississippi headquarters room are, from the left, President G. Swink Hicks, Natchez, Mr. Winstead, and AMA Delegate J. P. Culpepper, Jr., Hattiesburg. (Photo by Bill Lively)
Conferences were held with Representatives Tom Abernethy, Arthur Winstead, and William M. Colmer as well as staff members and executive assistants of the three other representatives, Frank Smith, John Bell Williams, and Jamie Whitten. Dr. Hicks was accompanied by MSMA executive secretary Rowland B. Kennedy and assistant exec- utive secretary Charles L. Mathews.
“The state of Mississippi should be grateful for the exercise of statesmanship by our representa- tives and senators,” Dr. Hicks reported. “They have a solid grasp of national issues and view the legislative scene with practical reality which is paying off for Mississippi.
“We can voice only the highest praise for their understanding of medical legislative problems,” President Hicks continued, “and for their willing- ness to study and understand complex socioeco- nomic issues affecting the health of all Ameri- cans.”
During the AMA sessions, numbers of the con- gressional delegation and their staff members vis- ited the meeting headquarters hotel to confer with MSMA officers and AMA delegates J. P. Culpep- per, Jr., Hattiesburg, and John F. Lucas, Green- wood. Participating in the conferences and acting as a co-host in the Mississippi headquarters room was Dr. Raymond F. Grenfell, Jackson, who pre- sented a scientific exhibit during the meeting.
Dr. Hicks said that neither Senator Eastland nor Senator Stennis was able to be at Washington during the meeting but that contact was made with each office.
Magnolia to Store Emergency Hospital
Magnolia will receive and store a 200-bed Civil Defense emergency hospital in the near future, according to Bob Crook, state civil defense di- rector. The contract with the federal government was signed in early November, said Crook.
The hospital will be stored for use in the event of any major disaster. Crook said he feels the hospital is needed in Magnolia because of its geo- graphic location near Baton Rouge and New Orleans. People from those areas would seek shel- ter in Magnolia and surrounding territory in case of a major disaster, he explained.
The complete unit packed will occupy 1,600 cubic feet of storage space. It includes a power generator, 200 folding beds, two operating rooms, operating equipment, drugs, and other supplies to operate a complete field hospital.
Dr. A. V. Beacham will act as medical officer in Magnolia for the unit.
Cancer Specialists Say Surgery Best Weapon
Two internationally known cancer specialists told Mississippi physicians attending the Third Cancer Seminar that surgery is still the best weapon.
Dr. Alexander Brunschwig and Dr. David A. Karnofsky, both of the Memorial Center for Can- cer and Allied Diseases, New York City, delivered lectures and participated in panel discussions dur- ing the seminar. Held at the University Medical Center Dec. 1, the program was financed by the Mississippi Division, American Cancer Society.
Dr. Brunswig discussed carcinoma of the cervix
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JOURNAL MSMA
and other pelvic tumors during his lectures. “We have to see what modern surgery can do. And I mean modern surgery,” he said.
Dr. Brunswig is attending surgeon and chief of the gynecological service at the Memorial Center.
Speaking on “The Current Status of Chemo- therapy in Cancer Treatment,” Dr. Karnofsky said four classes of drugs have been found to combat cancer with a good degree of effectiveness — after surgery and x-ray are not feasible. The classes are the nitrogen mustard group, antimetabolites, ster- oid hormones, and miscellaneous.
He stressed that “at this point these drugs are not curative.”
Dr. Karnofsky, who is attending physician in the department of medicine at Memorial and James Ewing Hospitals in New York, also spoke on “The Treatment of Lymphomata With Illustra- tive Cases.”
More than 60 physicians from throughout the state registered for the one-day meeting.
Mississippi panelists included Dr. Warren N. Bell, Dr. Dewitt T. Brock, Jr., Dr. Guy T. Gilles- pie, Dr. John T. Kitchings, and Dr. Albert L. Meena, all of the University Medical Center, and Dr. Dawson B. Conerly, Jr., Hattiesburg; Dr. George T. Martin, Vicksburg, and Dr. William L. Thornton, Meridian.
Central Society Names Sutherland President-Elect
New officers of Central Medical Society are shown with Horace Cotton, executive editor of Medi- cal Economics, who spoke to the group’s Dec. 6 meeting. Standing from left to right are Dr. C. G. Sutherland, president-elect; Dr. Thomas J. Safley, program chairman; Mr. Cotton, and Dr. George E. Gillespie, secretary. Seated from left to right are Dr. William A. Smithson, retiring president, and Dr. Clyde A. Watkins, president.
Doctor Delegates Named For White House Meet
Twenty-five Mississippi delegates will represent the state at the 1960 White House Conference on Aging at Washington, January 9-12. Named by Governor Barnett under the 1958 act of Congress authorizing the giant meeting, the group includes eight physicians.
The four day conclave will seat 2,800 delegates among whom are more than 1,700 representatives of the 50 states. Other voting seats are appor- tioned among national organizations having an in- terest in the field of aging and agencies of the fed- eral government. The formula for state apportion- ment is four times the number of members in the House of Representatives.
Named by Governor Barnett as delegates are Drs. Temple Ainsworth, Jackson; L. W. Brock, McComb; Stanley A. Hill, Corinth; W. L. Jaquith, Whitfield; H. H. McClanahan, Columbus; H. C. Ricks, Sr., Jackson; and George E. Twente, Jack- son. Dr. David B. Wilson, Jackson, another physi- cian delegate, is a member of the Mississippi Council on Aging.
Other delegates include business executives, teachers, ministers, and government officials in the legislative, administrative, and welfare fields. Rowland B. Kennedy, MSMA executive secretary, is a delegate.
The conference will review reports of activities in 20 areas concerning the aging. Among these are health care and related services.
Edentulousness: A Biting Report
Got a case of edentulousness? No? But one out of every eight Americans has, according to a re- cent report released by the U. S. Department of Health, Education, and Welfare.
About 22 million persons constituting 13 per cent of the U. S. population are victims of the toothless tongue twister — total loss of permanent teeth. The report classified persons as edentulous where total loss had occurred whether dentures are utilized or not.
Factors exerting apparent influence on loss of teeth include age, area of residence, income, and education. Virtually no person under age 15 is edentulous, the report stated, and only one per cent in the 15 to 24 bracket were found to have
35
JANUARY 1961
MEDICAL ORGANIZATION / Continued
lost all permanent teeth. The proportion increases up to 22 per cent of 45 to 54 group and zooms to 67 per cent among Americans past their seventy fifth birthday.
Southerners keep their teeth at a better rate than all other Americans at a low 12.3 per cent. The northeast and west were next at 12.5 but mid- westerners were found to be 14.4 per cent eden- tulous. Women suffer loss of permanent teeth more often than men at a seven to six ratio, the report continued.
Rural citizens experience edentulousness at a slightly higher rate than urban dwellers. Income appears to exert a pronounced influence related to purchase of dental care and diet. Families with annual incomes of $2,000 and under were 24 per- cent affected while units of $7,000 and up suffered total tooth loss at a rate of only nine per cent.
Where the head of the family had less than five years of formal schooling, 19 per cent of all family members were edentulous but the rate was a modest six per cent where the household master held a college degree.
Parley on Care For Aging Held
Premeeting highlight of the December Washing- ton AMA clinical session was the National Med- ical Services Conferences on Medical Care for the Aged, a project of the AMA Council on Medical Service. Chief topic of the conclave, held on the day before the session formally opened, was re- cently enacted national legislation on senior health care programs under extension of the old age as- sistance and the newly enacted medical assistance for the aging.
Representing the Mississippi State Medical As- sociation were Drs. G. Swink Hicks, Natchez, president; J. P. Culpepper, Jr., Hattiesburg, and John F. Lucas, Greenwood, AMA delegates; Rowland B. Kennedy, Jackson, executive secre- tary; and Charles L. Mathews, Jackson, assistant executive secretary.
The all day conclave was devoted to orientation and explanation of Public Law 86-778, the 1960 amendments to the Social Security Act, which passed the recent Congress after defeat of H.R. 4700, the Forand bill. Speakers included both AMA and high government officials. Presiding was Dr. J. Lafe Ludwig, Los Angeles, chairman of the Council on Medical Service.
Public Health Service Urges Influenza Vaccination
Three epidemic waves of Asian influenza in the United States in the last three years have prompt- ed the Public Health Service to urge continuing vaccination, especially of the high-risk groups: the aged, the chronically ill, and pregnant women.
According to Leroy E. Burney, surgeon general, it was found that a new antigenic variant, the Asian strain, because of its widespread introduc- tion and the general lack of resistance to it, was the direct cause of the excess numbers of deaths, not only in the total population but most markedly among the chronically ill, the aged, and pregnant women.
The two outbreaks of influenza which swept the United States in the fall of 1957 and the winter of 1958 resulted in 60,000 more deaths than would be expected under normal conditions. There were, in addition, more than 26,000 excess deaths dur- ing the first three months of 1960 which also were considered to be the result of influenza.
An investigation by the Surgeon General’s Ad- visory Committee on Influenza Research led the Public Health Service to recommend that these high-risk groups be routinely immunized each year:
1. Persons of all ages who suffer from chronic debilitating diseases.
2. Pregnant women.
3. All persons 65 years or older.
The surgeon general has recommended that im- munization of these high-risk groups be started now and continued annually, regardless of the predicted incidence of influenza for specific years. “The unpredictability of recurrence of influenza and its continued endemic occurrence are well known,” he said.
Ob-Gyn Board Schedules Exams
The Part I examinations of the American Board of Obstetrics and Gynecology will be conducted Jan. 13 in principal U. S. cities and some military installations outside the continental limits.
The board has announced that the Part II ex- aminations, oral and clinical, are scheduled for April 8 through 15, 1961. The Part II examina- tions, to be held at the Edgewater Beach Hotel, Chicago, 111., will be conducted by the entire board.
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Home Fires Burning With Heavy Toll of Life
Approximately 7,300 lives are lost each year in the continental United States because of fires or burns by other means, according to the Metro- politan Life Insurance Company. Of this total, about 5,700 or nearly four fifths, occur in and about the home.
TABLE 1
DEATHS CAUSED BY FIRE AND BURNS BY OTHER MEANS
By Place of Accident United States, 1956-58
|
Place of Accident |
A verage Annual Number of Deaths |
Per Cent of Total |
|
Total* |
7,282 |
100 0 |
|
Home |
5,721 |
78.6 |
|
Farm |
1 15 |
1.6 |
|
Industrial place |
389 |
5.3 |
|
Street and highway |
45 |
.6 |
|
Public building |
210 |
2.9 |
|
Resident institution |
168 |
2.3 |
|
Other specified places |
189 |
2.6 |
|
Place unspecified |
445 |
6.1 |
* Includes: Accidents caused by fire and explosion of combustible materials and accidents caused by hot sub- stances, corrosive liquids, steam, and radiation. The latter category accounts for approximately 750 deaths a year, with about 400 due to home accidents. The figures in this table do not include transport, firearm, or dynamite accidents.
Source: Reports of the National Office of Vital Statis- tics.
As Table 1 shows, the toll from such accidents in the home is nearly 15 times that in industrial places, including mines and quarries. Further- more, the number of nonfatal injuries from burns sustained in the home is exceedingly large.
Data from the U. S. National Health Survey indicate that in the year ended June 1959 there were 929,000 such injuries serious enough to be medically attended or to cause at least one full day of restricted activity. As a consequence of these injuries, persons 17 years of age and over stayed away from their jobs a total of 432,000 days dur- ing the year.
The large majority of deaths from fires in the home result from accidents in which one or two people are killed. However, conflagrations causing five or more deaths are not infrequent. In the five- year period 1955-59, there were at least 154 such
catastrophes in the United States, according to in- formation compiled from various sources by the Statistical Bureau of the Metropolitan Life Insur- ance Company.
Young children and old people experience the highest death rates from fires and burns by other means, as may be seen in Table 2. The mortality rate among infants is higher than that for any other age group under 65 years; the rate decreases to a minimum in adolescence and then rises pro- gressively with advance in age, slowly at first but very rapidly past age 65.
Older people, because of physical impairments or weakness, often find it difficult to escape from a burning building, and because of decreased agility they are particularly vulnerable to the hazard of having their clothing ignited by an open fire or other flame.
Pointing up the death toll at the younger ages, the National Fire Protection Association reports that in 1959 about 3,300 children under age 14 lost their lives in fires and explosions of all kinds in the United States, and estimates that nearly one third of them died because they were left alone or in the care of a baby sitter unable to cope with the situation.
It is also apparent from the table that the death rate for males is higher than that for females at every age period except 1-14 years, where the rate is somewhere greater for the girls.
TABLE 2
DEATH RATES FROM FIRE AND BURNS BY OTHER MEANS*
By Sex and Age United States, 1956-57
|
Age Period (Years) |
Average Annual Death Rates Per 100,000 TOTAL MALES FEMALES |
||
|
All ages |
4.2 |
4.8 |
3.7 |
|
Under 1 |
7.7 |
7.9 |
7.6 |
|
1-4 |
. 7.3 |
6.8 |
7.7 |
|
5- 9 |
2.8 |
2.2 |
3.5 |
|
10-14 |
1.3 |
1.2 |
1.4 |
|
15-19 |
1.1 |
1.3 |
1.0 |
|
20-24 |
1.7 |
2.1 |
1.3 |
|
25-34 |
2 2 |
3.0 |
1.4 |
|
35-44 |
3.0 |
4.0 |
2.0 |
|
45-54 |
4.0 |
5.2 |
2.7 |
|
55-64 |
5.1 |
6.6 |
3.7 |
|
65-74 |
9.2 |
1 1.0 |
7.7 |
|
75-84 |
19.4 |
21.9 |
17.4 |
|
85 and over |
35.3 |
42.6 |
30.1 |
|
* Includes accidents |
in the house and elsewhere, except |
transport.
Source: Same as Table 1.
JANUARY 1961
37
MEDICAL ORGANIZATION / Continued
New Insurance Form Trims Paperwork
Office paperwork for Mississippi physicians will decrease in 1961, thanks to the association’s new version of the Health Insurance Council uniform claim form. The one page, 12 item, condensed form has been under development for seven years by the insurance industry and medical organiza- tion. Supplies of the new form will soon be avail- able to MSMA members at cost.
During the 1960 annual session, the Council on Medical Service observed that . . for years, the problem of paperwork required in preparing in- surance claims has been a major concern to the medical profession and insurance companies. The problem has increased rather than decreased be- cause more insurance covering medical, surgical, hospital, and accident care is now in force, more insurance companies have become active in under- writing this coverage, and each company inevi- tably developed its own claim form, resulting in a lack of uniformity and difficulty for the physician.”
The new single form for both individual and group contracts has been accepted by a vast ma- jority of the 800 American companies offering health insurance. Association spokesmen pointed out that office time saved in use of the single form will also effect a substantial monetary savings to the doctor over preparation of different forms from different companies. The HIC uniform form has been approved by AMA and MSMA.
John W. Nicholson, Jackson insurance execu- tive and Mississippi HIC chairman, congratulated the association upon adoption of the form, stating that . . we who are active in the Health Insur- ance Council want to assure you of our desire to cooperate with you in having the insurance car- riers of this state honor these standardized forms.”
Mr. Nicholson emphasized that state HIC mem- bers are anxious to assist physicians in expediting claims for professional services. Use of the new form, he added, can increase the service potential of claims adjudicators.
Association spokesmen said that samples of the new form will be sent to MSMA members during January together with purchase information. It is anticipated, they stressed, that the approved MSMA-HIC form will be available at substantially lower cost per pad than those offered commer- cially. Plans call for production of 25 sets (orig- inal and duplicate for the physician’s files) per pad.
FCC Assigns Physicians Radio Band
The Federal Communications Commission act- ed last month to assign radio frequencies for pri- vate use by physicians, hospitals, and ambulances, ending a long debated request for medical air channels initiated by AMA. Five new frequencies in the 152-162 megacycle band were set aside for hospitals and ambulances and eight was tabbed for doctors’ use.
MSMA spokesmen said that state physicians desiring two-way radio systems between automo- bile and office or home may now apply for licen- sure. No special qualification in radio is required since all equipment will be radiotelephone or voice transmission.
Frequencies assigned hospitals and ambulances are exclusive and the eight special emergency radio service frequencies assigned physicians will be shared with Red Cross and similar organiza- tions. Public health agencies will not be permitted to use any of the 13 frequencies, since the local government service bands are available to them.
Medicine’s initial application to FCC was for frequency assignments in the 40 megacycle band. The final decision is officially designated Second Report and Order, Docket No. 13273, Federal Communications Commission, October 20, 1960.
“ Last night 1 broke two arms, two legs, and one commandment.”
38
JOURNAL MSMA
Public Health Workers Note State, National Issues
Mississippi public health workers considered state problems such as the coroner system and national issues including federal medical care programs during their 24th annual meeting.
Held in Jackson Dec. 7-9, the convention was planned on the theme “Maximum Health and Good Living.” A number of lectures and eight section meetings composed the program.
Speaking to the Dec. 8 general session, Dr. A. L. Gray, state health officer, said any Missis- sippi participation in the federal-state medical care program for the aged “should be a part of the general official public health program."
Said Gray, “I am not proposing that Missis- sippi does or does not participate in the medical care program. ... I am saying that if and when the state of Mississippi launches into a medical care program of this type, we have dispersed throughout the state about 750 medically oriented people in official public health who by their par- ticipation could assure a much greater degree of success with desirable conservatism than could be developed in many years by an agency or de- partment which is not statewide in scope or medi- cally oriented.”
During the same session, Dr. Hugh R. Leavell, professor of public health practice of the Harvard School of Public Health, delivered the Memorial Address honoring the late Dr. Felix J. Under- wood. Dr. Underwood was state health officer for many years before his death in 1958.
In later Thursday activity. Dr. Ruth Hagstrom, director of the Clay and Oktibbeha County Health departments, advocated a medical ex- aminer system to replace coroners in Mississippi. Speaking for the Vital Statistics Section, Dr. Hagstrom branded the layman-elected coroner system “inadequate and archaic.”
“An adequate medical examiner system would be the best answer in obtaining accurate and complete death certificates,” she said. “And this knowledge is important in our efforts to prevent disease and death.”
According to Margaret E. Rice, head of the Vital Statistics Bureau in the State Board of Health, 2,485 deaths or 12 per cent of the 1959 total were turned in with cause of death unknown.
Dr. Hagstrom did not elaborate on how the state system should be set up. “Other states’ sys- tems would have to be studied and the most effective for Mississippi may be parts of several different states efforts,” she explained. “My main contention is that the coroners system is inade-
quate and we need more accurate death certifi- cates than we are getting now,” she said.
During the closing session of the three day meeting, Howard E. Boone, special program rep- resentative for the State Board of Health, was made president-elect of the Mississippi Public Health Association. Miss Grace Huffman of Sum- mit was installed as new MPHA president suc- ceeding Z. E. Oswalt of Jackson.
Among its last actions, the MPHA proposed four enactments for the consideration of the next legislative session. Charging that Mississippi is one of the few states with “most ineffective regu- latory laws and capabilities” regarding food and drugs, the group asked the state’s lawmarkers to: 1. Reduce the processing and marketing of poor quality and otherwise unsafe food and drugs. 2. Provide for proper labeling of necessary and uni- versally used items. 3. Control the use of unneces- sary additives and adulterants in both food and drugs. 4. Repeal or amend such laws as are now in existence in relation to food and drugs, sub- stituting therefor a model food and drug law or laws which would provide the State Board of Health with the necessary authorities, direction and funds to develop essential regulatory and con- trol activities.
Nursing Home Center Building in 1961
The nation’s insurance and pharmaceutical in- dustries are combining forces to finance construc- tion and staffing of Washington’s newest addition to its galaxy of famed buildings. This will be the International Nursing Home, Research, Educa- tional, and Service Center, an $11 million project to be started this year.
The center will be a base of operations for nurs- ing home administrators with a training school, one of the world’s largest scientific libraries on care of the aging and chronically ill, a completely equipped model nursing home in full operation, a permanent display of nursing home equipment, and extensive research facilities.
Spokesmen for the sponsoring industries said that present nursing home facilities provide ap- proximately 450,000 beds in 14,000 homes and about 10,000 bed-and-board establishments. With an estimated 20 million Americans in the over 65 age bracket by 1975, one million new nursing home beds will be required to provide the opti- mum of one bed per four aged persons.
The entire cost of the $11 million project will come from private sources with neither federal nor state governmental participation.
JANUARY 1961
39
MEDICAL ORGANIZATION / Continued
10,000 Attend ASC Clinical Congress
JAMES C. GRIFFIN, JR., M.D.
Jackson, Mississippi
Research reports, lectures, panel discussions, postgraduate courses, films on surgical technique, and operative telecasts composed the program of the American College of Surgeons 46th Clinical Congress.
Approximately 10,000 persons, including 7,000 practicing surgeons, attended the October Con- gress which was held in San Francisco. More than 1,000 physicians took part in the program.
During the meeting, Dr. I. S. Ravdin of Phila- delphia, chairman of the Board of Regents and vice president for medical affairs of the Uni- versity of Pennsylvania, was installed as the new president of the college. The membership was raised to approximately 24,000 with the initiation of 1,170 surgeons as Fellows of the American College of Surgeons.
One of the highlights of the meeting was a talk by Dr. Paul R. Flawley, director of the American College of Surgeons, to the National Association of Science Writers. Dr. Hawley dis- cussed the sliding scale of fees for surgeons, which he maintained was practical and valid. He felt that the most valid reason for variable fees is that the poor, as well as the better-off, must have surgical care when they need it. Yet, he said, if the level is placed low enough for every- one to afford it, surgeons would find it difficult to make a reasonable living.
Dr. Hawley noted that the ACS Board of Regents has defined a reasonable fee as that which is commensurate both with the service rendered and with the reasonable ability of the patient to pay. He said that no family should have to forego any necessity in order to pay a surgical fee. By the same token, he continued, persons should include surgical care in their budgets.
Dr. Hawley encouraged a frank discussion with the patient prior to the presentation of a bill and said satisfactory agreements usually could be worked out this way. He said that the discussion should include the hospital bill and other charges which the patient has to meet and that the patient should be shown that these costs have risen at a substantially higher rate than surgeons’ fees. He stressed the importance of educating the people
to the necessary cost of medical care and that people must recognize that medical care is as es- sential as food, rent, and clothing and budget accordingly.
Among the biggest attractions of the meeting were the 14 live telecasts of operations. The surgi- cal procedures ranged from a radical mastectomy and pulmonary resection to cholecystectomy and open reduction of fractures. It was noted by sur- geons from this area that once the skin incision had been made, the cautery was used throughout the procedure to divide muscles and fascia and for hemostasis regardless of whether it was correction of undescended testicle or radical mastectomy or pulmonary resection.
The forum on fundamental surgical problems is one of the most important events of each con- gress. At the 1960 meeting, 257 reports of re- search in progress throughout the country were presented. Heretofore, the papers had been col- lected following the forum and were bound and sold as a volume several months later. However, this year the papers had been collected and bound prior to the congress and were on sale at the beginning on the meeting.
The advocates of hemigastrectomy and vagot- omy for duodenal ulcer continued to present studies indicating that this procedure may replace others as a choice of therapy for duodenal ulcer. Dr. William Scott of Nashville presented a series of 739 patients that had been followed for 13 years. The series showed an extremely low ulcer recurrence rate of .5 per cent and indicates that the procedure carries a lower operative mortality than the 75 per cent subtotal gastrectomy.
The 47th Clinical Congress is scheduled for Oct. 2-6 in Chicago.
Jones County Names Officers
Mrs. Charles Guice will serve as president of the Jones County Medical Auxiliary during 1961. She succeeds Mrs. Frank L. Ramsey who was named vice president at the group’s November meeting.
Other officers elected were Mrs. Eugene Busch, president-elect; Mrs. David W. McLean, secretary, and Mrs. James Waites, treasurer. All are from Laurel.
40
JOURNAL MSM A
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION
February 1961, Vol. II, No, 2
Intra-arterial Transfusion in the Treatment
of Hemorrhagic Shock
J. HURD GADDY, M.D. and DONALD DIEFENDORF, M.D.
Gulfport, Mississippi Baton Rouge, Louisiana
The purpose of this paper is not to present ad- ditional evidence to support or disprove any con- cepts about the method by which intra-arterial transfusion brings about a rise in blood pressure. The results obtained by the use of intra-arterial transfusion are presented and the technique of ad- ministering intra-arterial transfusion is explained.
The basis upon which intra-arterial transfusion is given is that blood given into an artery rapidly brings about a rise in blood pressure by raising the intra-aortic pressure, increasing coronary artery blood flow, and providing a sufficient vol- ume of blood against the pumping action of the heart to insure perfusion of vital organs, thereby reversing the entire shock state.
Restoration of blood volume and elevation of blood pressure is a fundamental surgical pro- cedure. The rapidity with which this is accom- plished determines in large part the immediate outcome and prognosis, particularly as pertains to cerebral and renal function and prevention of myocardial ischemia. The simplicity of intravenous transfusion has made this a universally acceptable method. This method replaces blood volume pri- marily and brings about a rise in blood pressure secondarily. The time interval between the initia- tion of intravenous transfusion and the elevation
Read before the Section on Obstetrics and Gynecology, 92nd Annual Session, Mississippi State Medical As- sociation, Jackson, May 10-12, 1960.
Because of its simplicity, intravenous transfusion has become a universally ac- ceptable method of restoring blood volume and raising blood pressure. This method re- places blood volume primarily and brings about a rise in blood pressure secondarily. Because of the time lapse between the initia- tion of intravenous transfusion and the elevation of blood pressure, intra-arterial transfusion is often a wiser choice of treat- ment. Through its use, blood volume is re- placed and blood pressure elevated simul- taneously. The authors discuss the technique of intra-arterial transfusion and report clinical results in 24 cases.
of blood pressure is considerable in many cases. However, in the use of intra-arterial transfusion the replacement of blood volume and elevation of blood pressure is accomplished simultaneously and rapidly.
There is no hesitancy to initiate surgery in these cases of severe shock, regardless of the blood pressure level. We have found that a surgical team working rapidly, often with little or no anesthesia in these practically moribund patients, can expose the large intra-abdominal and pelvic vessels, arrest the hemorrhagic process, and initiate intra-arterial
FEBRUARY 1961
41
TRANSFUSION / Gaddy and Diefendorf
transfusion more rapidly than another team can expose and cannulate a collapsed peripheral ves- sel. Nor do we close the abdomen while these pa- tients are still in shock, for it is advisable to keep these large vessels available and to have the added assurance that the failure to respond is not due to hemorrhage at the operative site.
TABLE I
ETIOLOGY OF SHOCK
Hem. at Surg 5
Rupt. Uterus 4
P.O. Hem 3
Incompat. Trans 3
Rupt. Tubal Preg 2
Rupt. T.O.A 2
Abrupt io Placenta 2
Amniotic Fluid Emb 1
Rupt. Renal Art 1
Terminal Ovarian Ca 1
Total 24
The technique of intra-arterial transfusion is simple and requires only the equipment which is available in the operating room. A simple trans- fusion set with a 15 or 18 gauge needle is used. This set may or may not be sterile; however, sterile technique is not of prime importance at this time. The usual plastic pumping set does not provide sufficient pressure; therefore the pressure in the system is provided by a sphygmomanometer bulb attached to the blood bottle air vent by means of a glass adapter. The needle is bent at a 45 de- gree angle to facilitate insertion and to prevent the inadvertent puncture of the posterior wall of the vessel. The needle is inserted in a cephalad direction. The blood pump must be manned by a responsible person since no air must be allowed to enter the vessel.
After removal of the needle, simple pressure and occasionally a silk suture at the puncture site
TABLE II
DURATION OF TRANSFUSION
|
I.V. Prior to |
LA. |
||
|
30 min. |
2 |
5 min. or less |
17 |
|
30-60 min. |
11 |
6-10 min. |
6 |
|
60-120 min. |
9 |
10-15 min. |
1 |
|
120 min. |
2 |
is all that is necessary to control the bleeding. The hypogastric artery is preferred as this artery may be ligated with impunity. As is the case in many instances, ligation of the hypogastric artery is a necessary and advisable step in the control of hemorrhage deep in the pelvis. In those cases where the external iliac artery was utilized, spasm and distal ischemia is prevented by perfusion of the vessel with procaine. In the immediate post- operative period, lumbar paravertebral sym- pathetic blocks are done.
These cases are taken from the Tulane Ob- stetrical and Gynecological Department at Charity Hospital in New Orleans. It will be noted that the etiology of shock in these 24 cases encompasses the various causes of shock encountered in obstetrical and gynecological surgery. Our service was not responsible for the early care in all of these cases, as Charity Hospital receives many patients from the smaller outlying hospitals. Some of these pa- tients were admitted to the service with no ob- tainable blood pressure, with and without previous treatment for shock.
Table II is presented to show that these are not ordinary cases of shock and would not respond to the usual shock measures. It will be noted that
TABLE III
AMOUNT OF BLOOD GIVEN
|
CC. |
I.V. Prior To l.A. |
I.A. |
|
500 |
2 |
7 |
|
500 |
3 |
9 |
|
700-800 |
0 |
4 |
|
1000 |
8 |
3 |
|
1500 |
4 |
1 |
|
2000 |
1 |
0 |
|
2000-3000 |
3 |
0 |
|
3000-4000 |
2 |
0 |
|
5000 |
1 |
0 |
22 of the 24 cases had received intravenous trans- fusion for a period greater than 30 minutes, where- as the blood given intra-arterially was given in less than five minutes in 17 cases and in less than 10 minutes in an additional six cases.
Table III is presented to show the large volume of blood which had been given intravenously as compared to the small volume of blood which was given intra-arterially. It will be noted that 20 of the 24 cases received less than 800 cc. of blood intra-arterially.
Table IV is presented to show that those cases
42
JOURNAL MSM A
were in profound shock and in 19 of the 24 cases no blood pressure was obtainable. Immediately following intra-arterial transfusion, 21 of the 24 cases had a blood pressure of 90/60 or above. The important point is that many of these cases had received and were rapidly receiving blood intravenously and 19 of the 24 had no obtainable blood pressure. However, immediately following intra-arterial transfusion which was given over a short period of time, 2 1 of the 24 cases had blood pressure of 90/60 or above. It was then possible to replace the estimated blood loss intravenously (often over a period of several hours) as the pump had been primed so to speak, and their cardiovascular system was now capable of han- dling this blood.
There were only three cases which failed to respond. One was a case of amniotic fluid em- bolus and a cardiac arrest prior to the initiation of
TABLE IV
B.P. AT TIME OF I.A.T.
70/40 1
50/0 1
40/0 3
0/0 19
intra-arterial transfusion. This patient had cardiac massage and intra-arterial transfusion, but failed to respond. Although, experimentally intra-arterial transfusion alone has caused the heart to start to contract after a period of asystole.
The case of intra-abdominal bleeding following vaginal hysterectomy had intra-arterial transfusion, and shortly afterward she developed cardiac arrest. Her blood pressure was unobtainable at the time the intra-arterial transfusion was started and al- though the heart did contract for a short period following the massage, the blood pressure was never obtainable and the patient expired a few minutes later. It was felt that treatment was started too late in this case.
One of the three patients who was in shock from prior incompatible blood intravenously failed to respond immediately. Ten minutes after comple- tion of the intra-arterial transfusion the blood pressure was heard at a 100/90 for a few mo- ments. She died ten hours later.
There were nine deaths in the series. That is to say none of these patients left the hospital alive. It must be remembered, however, that in only three cases did we fail to do what we set out to do with intra-arterial transfusion, that is to raise the blood pressure above shock levels.
The only complication which has occurred which could be attributed to intra-arterial trans- fusion was in one of the cases of far advanced ovarian carcinoma. This patient went into shock while having the large primary tumor mass re- moved and due to dense adhesions deep in the pelvis, the external iliac artery was used. Postop- eratively the patient developed spasm and ischemia and gangrene of the leg on that side. Surgery was
TABLE V
B.P. IMMEDIATELY AFTER I.A.T.
90/60 or above 21
0/0 — Amniot. Fluid Emb. With Cardiac Arrest Prior to I.A.T.
0/0 — P.O. Vag. Hyst. Bleeding Cardiac Arrest Immediately After I.A.T.
0/0 — Incompat. Blood Trans.
consulted for possible replacement of this segment of the vessel, however due to the extensive met- astatic disease known to exist and the fact that death was imminent, this procedure was not per- formed. The patient died five days postoperatively of pulmonary embolus. The ischemia and gan- grene proved at autopsy to be due to the dislodge- ment of an atheromatous plaque at the needle puncture site.
I would like to mention two other cases in which I have used intra-arterial transfusion and which are not included in this series. Both cases were comatose and had no obtainable blood pres- sure. Without the aid of anesthesia and without sterile surgical technique the abdomen was opened,
TABLE VI DEATHS
Incompat. Trans. 3
Amniot. Fluid Emb 1
P.O. Vag. Hyst 1
Massive Rectal Hem. 1
Post Mortem C/S 1
Terminal Ovarian Ca.
the hemorrhagic process was arrested, intra- arterial transfusion initiated. The patients' blood pressure rose over the next three or four minutes to that of 90/60 or above. The patients’ estimated blood loss was then replaced intravenously. Post- operatively one of the patients developed a wound abscess, otherwise their postoperative course was uneventful. ***
Gulf Aire Apartments (Dr. Gaddy)
FEBRUARY 1961
43
TRANSFUSION / Gaddy and Diefendorf
REFERENCES
1. Veal, et al.: The Physiologic Basis for Intra-arterial Transfusion in Severe Hypotension, South. M. J. 44:1096, 1951.
2. Kohlstaedt, K. G., and Page, I. H.: Hemorrhagic Hypotension and Its Treatment by Intra-arterial and Intravenous Infusion of Blood, Arch. Surg. 47:178, 1943.
3. Jones, et al.: Physiologic Mechanisms of Intra-arte- rial Transfusion. Surgery, 27:189, 1950.
4. Page, I. H.: Vascular Mechanisms of Terminal Shock, Cleveland Clin. Quarterly 13:1, 1946.
5. Robertson, et al .: Intra-arterial Transfusion, Exper- imental and Clinical Considerations, Surg. Gynec. & Obst. 87:695, 1948.
6. Veal, J. R.; Russell, A. S.; and Stubbs, D.: Intra-
arterial Transfusion, Indications and Technique, Am. Surg. 18:1150, 1952.
7. Haxton, H. A.: Intra-aortic Blood Transfusion, Lan- cet 1:622, 1953.
8. Mabney, J. V., et al.: Intra-arterial and Intravenous Transfusion, a Controlled Study of Their Effective- ness in the Treatment of Experimental Hemorrhagic Shock, Surg. Gynec. & Obst. 97:529, 1953.
9. Case, et al.: Intra-arterial and Intravenous Blood Transfusion in Hemorrhagic Shock, Comparison of Effects on Coronary Blood Flow and Arterial Pres- sure, J.A.M.A. 152:208, 1953.
10. Arty, C. P.; Salso; and Bromwell, A. W. : Intra- arterial Versus Rapid Intravenous Blood Trans- fusion, U. S. Armed Forces M. J. 6:313, 1955.
11. Seeley, S. F., and Nelson, R. M.: Intra-arterial Transfusion, Collective Review, Internat. Abstracts Surg. 94:209, 1952.
12. Collins, et al.: Intra-arterial Transfusion in Obstetrics and Gynecology, Am. J. Obst. & Gynec. 74:465, 1957.
CLINICAL CROSSTALK
Most research reports on clinical testing of new drugs are pointed and useful but snooty scientific balderdash does crop up now and then. The U. S. Armed Forces Medical Journal took the latter for a good natured skinning, by “translating” selected pas- sages from recent evaluation reports.
“We determined to conduct a controlled comparative evalua- tion of the most commonly used agents in order to assay their re- spective advantages and disadvantages.”
Translation : What else could we do with these samples? “Exhaustive perusal of the available literature revealed the paucity of experimentation in this area.”
Translation: Nothing in this week’s JAMA.
“Subjects were randomly selected without prior attention to inherent clinical variables.”
Translation: We used anybody we could get.
“The precise mechanism through which the response is mediated has not yet been defined.”
Translation: We don’t know what happened.
“We gratefully acknowledge the cooperation, in many areas of this study, of the Blank Laboratories.”
Translation: They paid us.
44
JOURNAL MSMA
The General Practitioner of 1970
LESTER D. BIBLER, M.D. Indianapolis, Indiana
John Galsworthy said, “If you do not think about the future, you cannot have one.”
There has been an unbelievable and miraculous evolution of the general practitioner since 1945. In 1944 I had the privilege of hearing indoctrina- tion lectures in Philadelphia where a group of doctors were told to organize their respective groups or someone would organize for them. At the 1946 AM A Convention in San Francisco, a committee was appointed. Among the members were Drs. Wingate Johnson, Paul Davis, Stanley Truman, and Holland Jackson. This culminated in that memorable meeting in 1947 in the Claridge Hotel in Atlantic City where 247 GP's started the Academy. That was the birth of the American Academy of General Practice.
THE ACADEMY’S AIMS
Since that time we have improved in stature by scientific study as well as numerical strength to over 26,000 doctors of general practice, the sec- ond largest medical group in the United States. This group is identified with the promise of:
1. Providing the best medical and surgical care possible to their patients.
2. A continuing course of postgraduate study by members to keep themselves abreast of modern therapeutics and techniques in order to provide the best family care to their patients.
In the interim of 13 years, we have seen the GP come forward in positive and constructive force to participate as a unit in local medical societies, hospital staffs, county, state, and national medical organizations. Today, over 40 delegates to the AMA are members of the Academy of Gen- eral Practice.
The general practitioner is doing well econom- ically. No longer is he paid with a razor back pig,
Read before the 12th Annual Scientific Assembly,
Mississippi Academy of General Practice, Jackson.
September 28 and 29, 1960.
The author discusses the evolution of the general practitioner and the birth of the American Academy of General Practice. He predicts what the place of the GP will be in the coming decade, and concludes, "If I had it all to do over again, I would still be a
a sack of potatoes, a chicken, or a piece of side meat. The modern GP has a nice home with all modern conveniences, transportation, and hospital privileges. His income is only limited by his desire to work and provide good care to his patients. In- come averages listed by various economists show the GP is a good member of the medical team.
What of the future medical school training, both undergraduate and graduate? Through the con- stant efforts of our staff organizations, education committees, and members, with the cooperation of many of the deans of our medical schools, the curriculum is gradually being changed. The dead- wood is being cleared and a more modern concept of medical education is being presented to our future doctors of medicine.
More courses will be presented to treat the pa- tient as a human, and the family as a unit and to recognize many of our psychosomatic and emo- tional problems.
GP SHORTAGE
Here is what Norman H. Davis, director of the medical program of the Sears-Roebuck Founda- tion says: “Regarding the future GP, I feel if the needs of this country are to be met, our schools must encourage — not discourage GP’s. The short- age of doctors for general medicine is very critical. It really is tragic that so many enter into special- ized fields, particularly in pediatrics, ob-gyn, and internal medicine.
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GP OF 1970 / Bibler
“Medicine and the public in general would benefit if young doctors spent three to five years as GP’s before deciding on specialization. This would enable the doctor to know the problems of dealing with patients, and at the same time, pro- vide an income to defray specialized training ex- penses. This may be in the future by 1970.”
FAMILY EXPERIENCE
One way medical students can secure good family experience is thru preceptorship training, general practice clinics, and family care plans. Different schools, different areas and environments will vary the manner in which the students secure this experience. The University of Tennessee, Ar- kansas, Kansas, Pennsylvania, Wisconsin, Mis- sissippi, and many others have such programs. After graduation the new doctors of medicine will take a two or three year residency.
Internships are passe and are tolerated only by precedent or by state laws which require an intern- ship before granting a license. Pennsylvania re- quires a rotating internship to practice while Johns Hopkins, which is nearby, provides straight in- ternships, that is internship in x-ray, surgery, med- icine, and other specialties. Consequently, many Johns Hopkins graduates are denied practice in Pennsylvania.
RECOGNITION OF TRAINING
Postgraduate education and training must be recognized and approved. This may be through the Academy by certificates of merit or by a co- operative Board of General Practice or similar organization. If we do not recognize and reward additional education and training for general practice, these young doctors naturally will take an extra year and limit their field of practice be- fore they are adequately prepared to do so. At the present time the AAGP offers no recognition for advanced training. This is one reason there is such an urgent need for good family doctors to act as the family physician, counselor, and ad- visor.
Solo practice is declining rapidly. The public is asking for continuous medical coverage and the demands on the modern family doctor are such that he cannot be on call 24 hours a day. Many now work 60 to 80 hours a week and think noth- ing of it. With unions recommending a 32 hour week, the medical profession will need either more doctors or less patients, or a supermarket type of medical and surgical care.
Rural communities will have a medical center similar to that recommended by the Sears and Roebuck Foundation. Here two or more doctors will operate a first class, modern, labor saving, and space saving health unit. This unit will be equipped to care for medical, obstetrical, and sur- gical emergencies, x-rays, treatment of fractures, and at least temporary bed care.
The doctors in urban areas will have an as- sociate or partner so that their practice is covered at all times and both the patient and the physician will feel secure. The patient will not panic be- cause the doctor is out of town and the doctor can relax because he knows his patients are provided with good medical care. There is a two year resi- dency program starting now which will stimulate further postgraduate training.
AMA PILOT STUDY
A pilot study has been approved by the AMA Council on Education and Hospitals and, in large measure, seems to meet specifications of the American Academy of General Practice. As out- lined by the secretary of Residency Review Com- mittee for General Practice, Dr. John C. Nune- maker, these key features of the intern-residency project are to be tested at the Baltimore City Hos- pital, the University of Kansas Medical Center, and the Indiana University Medical Center.
Heavy emphasis will be placed on outpatient service, including follow-up in the home, handling specialist referral, and social and rehabilitation services. Training in psychosomatic and emotional aspects of illness will be presented.
An integrated progressive program calling for work in internal medicine, pediatrics, and emer- gency room procedures, plus electives expected to consist of ob-gyn, radiology, and anesthesiology. Surgery will be confined to minor operations and emergency cases in this program.
TWO YEAR PROGRAM
The delegates of both the AMA and AAGP ap- proved reports urging a two year program as the minimum requirement prior to family practice and agreeing on most facets of the training. Exceptions raised by AAGP were that ob-gyn should be re- quired, and that surgery should have more em- phasis. In the future the academy plans to limit membership of new members to those meeting these requirements.
One point all doctors must be on guard against is that of retiring our elders by calendar year status. Many hospital surveys are now recommend- ing that all doctors past 65 have their hospital case
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records perused and checked and that physicians 70 and over should have a younger man sponsor or check their treatment and medical decisions. This may sound ridiculous but it has already been tried in one hospital in Indiana and was promptly defeated.
The 1970 general practitioner will be more alert with finer appointments and accommodations, well trained, and will do an outstanding job in providing the best medical and surgical care to his patients.
FIGHT FOR IDENTITY
However, the GP of 1970 will have to fight to maintain his identity as an individual. The present renewed assault to attempt a back door approach of socialized medicine is an ever present danger. It has been tried for the past 50 years.
The recent fiasco in Congress shows that the labor unions and the “do-gooders” are still trying to put across some type of Forand Bill legislation and the new doctors must be made aware of this danger. Do you know that the Student AMA House of Delegates Meeting in Los Angeles, Calif, refused to pass a resolution opposing the Forand Bill? There is urgent need to alert our young doc- tors and our future doctors that a desire for so- called “security” from the “great white father” is not the type of heritage that America was built on and if we accept such token of government supervision, then we are on the downward path of a decadent nation.
DISUNITY: A SERIOUS DANGER
Dr. Louis H. Bauer, who has served as both AMA president and chairman of the Board of Trustees and is now secretary general of the World Medical Association, states that a study of the situation in all countries shows that wherever there has been any halting of further intrusion by gov- ernment, it has been because the medical profes- sion stood as a unit under the leadership of a strong organization. Disunity is a serious danger to the profession in this country. If the doctors in the United States do not wake up and close ranks, medicine is all through as an independent pro- fession.
What can be done? There are several things: 1. Revive interest in and activity of local and na- tional medical societies. Make membership a badge of respectability, not a routine matter. Arouse the interest and urge participation of young doctors. 2. Develop “teeth” in grievance com- mittees. Suspend or expel the few fee-chiselers and fee-gougers who are debauching and disgracing the
profession. 3. Stop looking backwards and wishing for the “good old days.” Prepayment is here to stay, whether we like it or not. Guide it in the right direction. Face the fact that medical care has be- come expensive. Make every effort to deliver the highest quality medicine to all, at a price they can afford to pay. Prevent abuses of prepayment and insurance systems. 4. Inculcate the new physician in the traditional philosophy that medicine is a humanitarian profession, not a commercial trade. 5. Remember, when government takes over med- icine, it takes (and controls) all, not a part.
Danger signals are flying. Are we going to heed them or will we sit back smug, and complacent and utter those famous last words, “It cannot happen here.”
NEED FOR EXPERIMENTATION
Dr. F. J. L. Blasingame, executive vice presi- dent of the AMA, states that in the field of med- ical education there is a vibrant spirit of change, experimentation, and expansion. Working in a healthy climate of ferment and unrest, medical schools are examining the quality and content of their educational program. They are seeking the best possible ways of presenting a coordinated body of medical knowledge which will prepare the physician for practice in the changing scene of modern medicine. The entire profession must en- courage and assist all sound experimentation aimed at the goal.
Related to this is the need for better under- standing and liaison with labor, business, in- dustry, consumer groups, and other third parties involved in the provision and financing of medical services. We must prove to these parties that it is to their advantage to preserve the principle of freedom of choice of physician and the right of the medical profession to judge the qualifications and competence of physicians and hospitals. We must develop effective systems of disciplining un- ethical physicians and restraining those whose actions are damaging to the entire medical pro- fession.
THE GREATEST CHALLENGE
Dr. J. S. DeTar, past president of the American Academy of General Practice, said it is in this field, the field of physician-patient relationship, that the greatest challenge facing the profession lies. With the continued trend toward more and more spe- cialization, this problem will continue to rank first. Will this challenge be met? If so, how? It will be met by training of more family physicians — phy- sicians who will assume the responsibility for the
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GP OF 1970 / Bibler
continuing care of the patient and his family, who will call consultation when indicated but who will continue to exercise a guiding hand over the pa- tient’s medical and economic welfare.
This physician will be a generalist with thorough grounding in internal medicine. His undergraduate training will accent the patient as a person. His graduate work will be comprehensive, first two, then three years. His preparation in medicine, pediatrics, geriatrics, preventive medicine, re- habilitation, psychiatry, and trauma will be far more comprehensive than it is now. His obstetrics and surgical practice will depend on his training.
The production of such family physicians, in numbers adequate to meet the need, depends upon the medical school facilities and the staff members of the hospitals offering graduate training. They must recognize the urgency of the problem. Pres- ent indications that this challenge will be met are most encouraging. One must particularly cite the
work of the American Medical Association, the Association of American Medical Colleges, and the American Academy of General Practice.
In conclusion I believe that general practice is here to stay. There will always be a need for the family doctor as long as people become ill and women have babies.
The GP will be better trained and prepared for family practice. He will have modern equipment and facilities to practice modern up-to-date med- icine. In rural areas particularly, he must have ad- ditional surgical training. He will have more time for leisure to be with his family due to group or associate practice with other doctors. His hos- pital privileges will be guarded jealously as he will be required to continue his education and partici- pate in teaching and staff activities. He will be an asset to the medical team.
This I can honestly say: I have enjoyed being a general practitioner and if I could, I would do it over again.
445 North Pennsylvania Street
OLD EVIL: NEW ROOT
Three-quarters of all drug addicts, according to recent studies, became addicted in the course of medical treatment. Reason for the intensified studies is that many of the new drugs being intro- duced on the market have addicting properties which are recog- nized too late. In 1936, 90 per cent of all drug addicts used morphine, but today 73 per cent are addicted to the new synthetic drugs. Almost anyone can become addicted to drugs, according to Dr. Maurice Partridge, consultant psychiatrist at London’s St. George’s Hospital. But Dr. Partridge has found that persons of an “obsessional personality with tendencies towards excessive neat- ness, undue caution and conscientiousness” are less prone. Factors which are conducive to addiction are lack of caution, impulsive- ness, and emotionalism.
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Gallbladder Surgery in the Aged
JOHN S. BARR, M.D. Belzoni, Mississippi
During the past three years, the staff of the Belzoni Clinic has performed gallbladder surgery on a significant number of persons over 65.
These patients were afflicted with sundry con- comitant diseases which made a large majority of them poor surgical risks.
Of course, just being 65 or over does not make a patient a poor risk. Most persons who have sur- vived six and a half decades have a philosophic approach to life; they tend to be optimistic, ex- troverted, and cooperative. Their greatest evil is overindulgence in food — though many are free from obesity when they come to surgery because of the dietary restrictions forced upon them by a chronically diseased gallbladder.
A TYPICAL CASE
Mrs. W. R. C., age 82, was seen first in her home with acute right upper quadrant pain radiat- ing to the angle of the scapula. Severe nausea and vomiting accompanied this pain. Further study in the hospital confirmed the clinical diagnosis of acute cholecystitis with cholelithiasis.
This patient had a third degree A-V block due to arteriosclerotic heart disease. She had been decompensated, but was moderately well con- trolled with digitalis and oral diuretics, though mild ankle and foot edema occurred each after- noon.
Since medical and supportive measures failed to give relief, it was elected to do gallbladder surgery.
At operation, done under ether-oxygen, a thick walled gallbladder, three times normal size, was found. Time was taken for a meticulous dissection of the cystic duct and cystic artery. Failure to do this in order to get the patient off the table as soon as possible usually results in grief soon after the
Read before the 74th Semi-annual Meeting, Delta Med- ical Society, Belzoni, October 12, 1960.
It was once held that elderly gallbladder patients should be medically managed rather than surgically treated. Modern methods and increased longevity of life hare made surgery the first choice even in the aged.
The author considers technique and treat- ment along with justifications for surgery and necessary precautions. A case report is presented.
operation. The liver was scarred, grossly resem- bling an early cirrhosis. The common duct was slightly enlarged, though there was no palpable induration. The temptation to explore this duct was strong, but in the absence of a history of clin- ical jaundice, it was resisted.
Postoperatively, the patient remained comatose for four days. This was due to a combination of factors, but hepatic insufficiency was the principal cause. The blood urea nitrogen was elevated some, but urinary output remained adequate. Carefully controlled fluid therapy as indicated by clinical status and laboratory procedures was the mainstay of treatment. On the fourth day, the patient be- came responsive and began to take nourishment. Thereafter, her course was quite smooth. In the ensuing months following her cholecystectomy, her cardiac status has steadily improved.
JUSTIFICATIONS
It was once thought that “make-do” medical management should be used in lieu of surgery in elderly gallbladder patients. This is not the case. They are primary surgical problems; there is seldom justification for medical management. They should be operated upon as soon as the diagnosis has been made and the physiologic and patho- physiologic status has been determined. To pro- crastinate is to invite disaster.
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GALLBLADDER SURGERY / Barr
The discussion of technique will not be detailed, as it is well known and well documented. But some points should be mentioned.
First, the anesthesia. Carefully planned preop- erative sedation, followed by slow induction with 0. 1 per cent sodium pentothal, which in turn is followed by ether-oxygen, is the safest anesthesia.
Exposure is obtained through a subcostal (Kocher) incision. Other incisions are equally as good.
Every effort should be made to remove — rather than drain — the gallbladder. A well-organized team can remove the diseased organ with not much greater expenditure of time than is required to drain it.
The common duct should be explored only if absolutely necessary (as determined by history, operative findings, and operative cholangiog- raphy). A T tube is sometimes necessary, but it is a foreign body, and its prolonged presence will often have a morale lowering effect in the aged patient.
Of course, it is useless to operate upon a mori- bund patient. If myocardial decompensation is severe, if arteriolar nephrosclerosis has caused azotemia or if any concurrent killing disease proc- ess is present, then surgery obviously should not be done. In such situations a cholecystostomy un- der local anesthesia may offer relief.
PRECAUTIONS
Precautions include: ( 1 ) meticulous clinical ob- servation, (2) daily measurement of intake and output of all fluids, (3) daily electrocardiograms, (4) daily determination of body weight, and (5) daily determinations of plasma electrolytes. The plasma electrolyte concentrations determine the type and amount of fluids to be administered par- enterally each day. Plasma chlorides (normal 96 to 100 mEq per liter) and carbon dioxide (normal 25 to 35 mEq per liter) concentrations should show a sum of 127 mEq per liter. The serum sodium and potassium concentrations help to furnish an indication of acid-base balance as well as a key to fluid metabolism. A daily hematocrit furnishes valuable information.
Until the patient is ambulating freely and daily or oftener taking nourishment by mouth, determi- nations of serum sodium, potassium, chloride, and carbondioxide are mandatory for the intelligent management of the aged post-cholecystectomy patient.
While these procedures provide but crude in- dices of patient progress, they do represent some
steps in the right direction. Perhaps in the future, the complex processes of damage and repair will be more accurately understood.
During the immediate postoperative period and for three to five days thereafter, continuous gastric suction should be employed. Fluids by mouth should be limited because as the fluid returns through the tube, it brings with it electrolytes which must be carefully replaced.
SOLUTIONS OF CHOICE
If the sum of the carbon dioxide and chlorides is less than 125 mEq per liter, hypo-osmolarity exists. In the average adult, 1,000 milliliters of 3 per cent sodium chloride solution will usually suffice to produce iso-osmolarity. If hyper-os- molarity (carbon dioxide and chlorides greater than 130 mEq per liter) exists, then 5 per cent glucose in water is the fluid of choice.
In hypokalemia, add 80 mEq potassium chlo- ride for maintenance and another 80 (within a 24 hour period) for correction of the deficit. If this is given in one infusion, it should not be given at more than 60 drops per minute. In those pa- tients with renal insufficiency, potassium must be given with great caution.
Acidosis (lowered blood bicarbonate, i.e. car- bon dioxide concentration less than 25 mEq per liter) is corrected by infusion of 6/M sodium lactate or 6/M sodium bicarbonate. Alkalosis (carbon dioxide concentration greater than 29 mEq per liter) is corrected by infusion of 2 per cent ammonium chloride solution.
In hyponatremia, a hypertonic sodium chloride solution should be used. It must be remembered that normal saline solutions are good maintenance therapy, but will not suffice to treat a sodium def- icit. The above mentioned fluid and electrolyte therapy is contingent upon adequate urinary ex- cretion.
Some of the above solutions are not available commercially. They are, however, easy to prepare and sterilize in most hospitals.
CRITERIA OF SUCCESS
Euripides, one of the great Greek tragedians, wrote, “When death comes near, the old find that age is no longer burdensome.” This idea expresses the attitude of most old people toward necessary surgery. Physicians must accept the challenge of helping the elderly live out their lives in as much comfort and freedom as possible. If this assistance entails the removal of a diseased gallbladder, then this must be done, utilizing the above pre- cepts. ***
84 Church Street
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Expanding Opportunity for Service
In Public Health
A. L. GRAY, M.D. Jackson, Mississippi
I consider this annual meeting of the Mississippi Public Health Association an event of much im- portance, giving opportunity for all of us to con- sider together the vital and essential program of health protection and to gain new knowledge based on continuing experience in this state, other states in the nation, and in all nations in the world. Also, the pleasant and motivating privilege of maintaining the kind of warm friendship and un- derstanding between co-workers which brings about mutual cooperation is of great value.
This public health program in our state con- tinues to be recognized among the top statewide programs of the nation for some very good rea- sons. Chief among these reasons is the genuine spirit of cooperation and mutual support of all those who labor in this vital field, including you as members of the official health force with the indispensible support of private physicians, den- tists, hospital authorities, the nursing profession, other state departments, the executive and legis- lative branches of state government, and county and city officials.
NEW OPPORTUNITIES
Among all these groups there is an obvious de- termination that Mississippians shall have the best possible state of health which is so fundamental in general progress. But, we cannot maintain an ac- ceptable program in a rapidly changing society by standing still. We are challenged daily with new problems and new and expanding opportunities to apply our skills and knowledge.
May I discuss briefly a few of these new or ex- panding opportunities which we must translate
Read before the General Session, 24th Annual Meeting, Mississippi Public Health Association, Jackson, De- cember 7-9, 1960.
The author, who is executive officer of the Mississippi State Board of Health, dis- cusses the facets of public health which will probably be most important in the coming decade. He considers radiological health, civil defense, and medical care of the indi- gent among other items. The paper is con- cluded with a short discussion of dental health and accident prevention.
into responsibility required to keep our total pro- gram vigorous and effective in the 1960’s.
HOUSING PROGRAM
First, I must point out a revitalized public health facility construction program which I interpret as a tremendous trust and faith in the county health departments and support of the State Board of Health. Within the last 18 months federal, state, county and town officials have provided funds for the construction of eight main county health de- partment buildings, ranging in cost from $55,000 to $350,000. In the last 12 months this same lead- ership, working together in support of the public health program, has provided for construction of 34 branch health clinic or center buildings at a total cost of over a half million dollars. At least 12 to 15 more branch centers are being arranged for and will be under construction in the next six months.
Here I must give much credit and express thanks of public health workers and the people of the state to the Mississippi Commission on Hos- pital Care and the Public Health Service for chan- neling to these facilities a major portion of the funds required. Thus, in the last 18 months an
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PUBLIC HEALTH /Gray
outlay of $1,600,000 has been provided for local health department facilities. I consider this as recognition of what we in public health can do for Mississippi and a mandate that we do it — and certainly not a monument to what we have done. These new facilities afford expanding opportunity for more service, for better service, in increasing respectable environments. I cannot justify spend- ing $15,000 to $20,000 on each of many new branch clinic buildings to be used one or two part- days per month. As they are put into service you should see that health services are made available in them at regular intervals more frequently than once or twice per month. This will justify the faith and trust which are bringing them into being for a better health program.
RADIOLOGICAL HEALTH
X-ray and nuclear radiation are types of energy undergoing most rapid development and usage. The ability of these types of energy to penetrate solid and semisolid media, to produce chemical and physiological changes in human tissue, ani- mals, plants — all living matter — to create useful energy of many types, and to induce genetic changes in living matter which can be reflected in generations to come — yes, all of this demands public health evaluation and increasing control.
Today, we find radiation sources and extensive usage in every health department, most physicians’ and dentists’ offices, hospitals, and in many so- called professional offices (where they are used purely as advertising). And now, nuclear radiation usage becomes increasingly essential to economic, defense and health progress. In Mississippi today, there are about 50 users of nuclear isotopes who have well over 100 sources in their possession. Prospects are for rapid development of nuclear radiation energy in salt dome explosions, river channeling — these and other usages being added to construction of submarines and other ships on our Mississippi Gulf Coast.
In January of this year, the state health depart- ments of the nation were informed by the Atomic Energy Commission and the Public Health Service that the governor of each state was being requested to prepare to take over responsibility for nuclear radiation control from the Atomic Energy Com- mission as soon as possible. Prior to this time Congress had designated the Public Health Service as the federal agency responsible for national level radiation control. In August, Governor Barnett through executive letter designated the State Board of Health as the responsible state department in Mississippi to prepare itself for and develop a program of radiation evaluation and control.
This probability was anticipated in June at which time preparations were begun by employ- ing a health physicist with a broad background of experience and specialized training in radiation physics. At our regular Board of Health meeting last Monday, Dec. 5, regulations were adopted to implement control as a part of our general public health program. Without doubt, the next regular session of the Legislature will consider a model law which will further strengthen control of safe and proper maximum use of all types of radiation.
The new regulations will require, among other things, registration with the State Board of Health of all x-radiation and nuclear radiation equipment and sources to serve as a continuing index of the kind and amount of radiation being used now and in the future and give direction to control activities. Through monitoring consultation services of the physicist, those who use x-ray, fluoroscopes, radi- um, and nuclear radiation sources will be advised as to hazards to themselves and those they serve and informed of required corrective measures to reduce unnecessary radiation. First, we want to be sure that x-ray equipment being used in our own health program is with maximum efficiency and safety. Through the enthusiastic material help of the State Department of Civil Defense, Surplus Property Commission, U. S. Public Health Service, and others, necessary equipment and laboratory capability are being developed. You will hear more and participate more in the near future about this, another example of expanding opportunity in public health.
CIVIL DEFENSE
For several years national, state, and local efforts have been directed at developing a work- able program of civil defense. These efforts have apparently not kept pace with the rate of increase of possibility of a world-wide war of annihilation. Interest and effective action have been sporadic and still leave much to be done in preparation to cope with a serious catastrophe. More recently, action in Washington designated the public health service to take such steps with state health depart- ments as would result in state and local health agencies accepting leadership in developing pro- grams which would make official health agencies capable of mobilizing all health and medical care facilities and professions for casualty and medical needs when and where needed. This would, of course, be a part of total civil defense effort and enmeshed into the State Civil Defense program as a whole. We are planning for, and anticipate, max- imum participation of all state and local health department personnel, capabilities, and facilities.
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Preparation for this task is a new opportunity which we hope materializes in the next few months in cooperation with state and federal civil defense agencies and the U. S. Public Health Service.
The first move in that direction would be an in- tensive in-service training program for all official public health employees in mass emergency med- ical and health care in all ramifications. Another facet of preparation will likely be decentralization of medical and health emergency stockpiles of supplies from a few regional storage centers in the southern states to local control under management of county health departments. Along with this will need to be developed voluntary, but effective, par- ticipation by physicians, hospitals, nurses, dentists, pharmacists, and all other professional com- petencies in the fields of medical and health care and environmental health protection. This is another example of need and demand for adapt- ing capabilities of public health workers and facil- ities under their control to changing and new de- mands.
CARE OF THE AGING INDIGENT
A more recent development at a national level was the passage of the Kerr-Mills legislation to provide medical, dental, hospital, nursing, and other health care services to those over 65 years of age and on welfare rolls and to those not on welfare, but who might be considered medically indigent or unable to provide all their medical care needs. Funds for financing this program in Mississippi would be primarily from federal sources to be matched by a much smaller propor- tion of state funds.
I am not proposing that Mississippi does or does not participate in this medical care program. Nonetheless, I am firmly convinced, as are all other state health officers, that if it is instituted, it should be as a part of the general official public health program rather than setting up still another health agency which would not have the advantage of experienced health administrators nor health and medically oriented staff. Our existing health personnel and facilities in Mississippi are statewide in scope of activities and facilities. Public health is already involved in many activities relating to the medical and health needs in all groups and can develop, or already have established, working relations with physicians, hospitals, dentists, nurs- ing homes, pharmacists, and others who must render the various services that might be provided under such a program. In its final analysis such a program as this legislation might provide with maximum state matching could become an ef- ficient reality only to the extent that the profes-
sional people who would be called on to render the various services would organize and agree to render the services under acceptable standards developed primarily by these groups working as a whole.
I am saying that if and when the state of Mis- sissippi launches into a medical care program of this type, we have dispersed throughout the state about 750 medically oriented people in official public health who by their participation could as- sure a much greater degree of success with de- sirable conservatism than could be developed in many years by an agency or department which is not statewide in scope or medically oriented.
DENTAL HEALTH
Certainly, one of the most common deficiencies in general health is in the field of dental health. Recognizing this relative deficiency, a new dental health unit is now in operation