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Summary of Actions of House of Delegates Page 57
July, 1970
VoI.138/No.1 Contents page 5
HEALTH SCIENCES LlBRAR'«.
BALTlHkX^
Flagyl
brand of
metronidazole
vaginitis
therapy
I
The effectiveness of Flagyl in Trichomonas vaginalis vaginitis has been so constant that use of less effective agents would seem to invite unnecessary failures. ■ The simplicity, completeness and persistence of cures with Flagyl qualify it as the logical first therapeutic. choiceJiT trichomonal infections.
Ten-day treatment with Flagyl oral tablets has replaced a multitude of untidy douches, powders, creams and jellies.
Flagyl is the only medication available that is able to reach all the crypts, glands and cavities of the female urogenital system as well as reservoirs of reinfection in male trichomonas carriers.
Flagyl eradicates resistant, deep-seated invasions of Trichomonas vaginalis and consistently produces cure rates above 90 per cent and often as high as 100 per cent in large series of patients. When the diagnosis is positive, Flagyl is positive.
Indications: For the treatment of trichomoniasis in both male and female patients and the sexual partners of patients with a recurrence of the infection provided trichomonads have been demonstrated by wet smear or culture. ■ Con- traindications: Evidence of or a history of blood dyscrasla, in patients with active organic disease of the central nervous system, and the first trimester of pregnancy. ■ Warnings: Use with discretion during the second and third trimesters of pregnancy and restrict to patients not cured by topical measures. Flagyl is secreted in the breast milk of nursing mothers; it is not known whether this can be injurious to the newborn. ■ Precautions: Mild leukopenia has been reported during Flagyl use; total and differential leukocyte counts are recommended before and after treat- ment with the drug, especially if a second course is necessary. Avoid alcoholic beverages during Flagyl therapy because abdominal cramps, vomiting and flushing may occur. Discontinue Flagyl promptly if abnormal neurologic signs occur. There is no accepted proof that Flagyl is effective against other organisms and it should not be used in the treatment of other conditions. Exacerbation of moniliasis may occur. ■ Adverse Reactions: Nausea, headache, anorexia, vomiting, diarrhea, epigastric distress, abdominal cramping, constipation, a metallic, sharp and unpleasant taste, furry or sore tongue, glossitis and stomatitis possibly associated with a sudden overgrowth of Monilia, exacerba- tion of vaginal moniliasis, an occasional reversible moderate leukopenia, dizziness, vertigo, drowsiness, incoordina- tion and ataxia, numbness or paresthesia of an extremity, fleeting joint pains, confusion, irritability, depression, insomnia, mild erythematous eruptions, “weakness,” urticaria, flushing, dryness of the mouth, vagina or vulva, vaginal burning, pruritus, dysuria, cystitis, a sense of pelvic pressure, dyspareunia, fever, polyuria, incontinence, decrease of libido, nasal congestion, proctitis, pyuria and darkened urine have occurred in patients receiving the drug. Patients receiving Flagyl may experience abdominal distress, nausea, vomiting or headache if alcoholic beverages are consumed. The taste of alcoholic beverages may also be modified. ■ Dosage and Administration: in the Female. One 250-mg. tablet orally three times dally for ten days. Courses may be repeated if required in especially stubborn cases; in such patients an interval of four to six weeks between courses and total and .differential leukocyte counts before, during and after treatment are recommended. Vaginal Inserts of 500 mg. are available for use, particularly in stubborn cases. When the vaginal inserts are used, one 500-mg. insert is placed high in the vaginal vault each day for ten days and the oral dosage is reduced to two 250-mg. tablets daily during the ten-day course of treatment. Do not use the vaginal Inserts as the sole form of therapy. In the Male. Prescribe Flagyl only when trichomonads are demonstrated in the urogenital tract, one 250-mg. tablet two times daily for ten days. Flagyl should be taken by both partners over the same ten-day period when It is prescribed for the male in conjunction with the treatment of his female partner. ■ Dosage Forms: Oral tablets 250 mg. Vaginal Inserts 500 mg.
G. D. SEARLE & CO.
Research in the Service of Medicine
941
Illinois Medical Journal
volume 138, number 1 ]^dy, 1970
Editor - Theodore R. Von Dellen, M.D.
Managing Editor Richard A. Ott
Medical Progress Editor Harvey Kravitz, M.D.
Editorial Assistant - - - Michaelyn Sloan
Advertising Manager John A. Kinney
Executive Administrator Roger N. White
J
\
CONTENTS
! ILLINOIS STATE
I MEDICAL SOCIETY
I '
\ ! 360 N. Michigan Ave., Chicago, 60601
I OFFICERS
J. Ernest Breed, President
55 East Washington Street, Chicago 60602 L. T. Fruin, President-Elect
5 Citizen's Square, Normal, 61761 George C. Shropshear, 1st Vice-President 1525 East 53rd Street, Chicago, 60615 C. J. Jannings, III, 2nd Vice-President 101 East Center Street, Fairfield, 62837 Jacob E. Reisch, Secretary-Treasurer
1129 South 2nd Street, Springfield 62704 jPaul W. Sunderland, Speaker
214 North Sangamon St., Gibson City, 60936 Andrew J. Brislen, Vice-Speaker j 6060 South Drexei Blvd., Chicago 60637 Willard C. Scrivner, Chairman of the Board 4601 State Street, East St. Louis, 62205
TRUSTEES
I Joseph L. Bordenave, 1st District (1971)
) 1665 South Street, Geneva, 60134
[William A. McNichols, Jr., 2nd District (1971) 101 West First Street, Dixon, 6^021 jFredric D. Lake, 3rd District (1972)
■ 1041 Michigan Avenue, Evanston, 60202
I James B. Hartney, 3rd District (1973)
I I 410 Lake Street, Oak Park, 60302 I [Frank J. Jirka, 3rd District (1971) i 1 1507 Keystone Ave., River Forest, 60305
William M. Lees, 3rd District (1971)
I 6518 N. Nokomis, Lincolnwood, 60646 Frederick E. Weiss, 3rd District (1973)
! 15643 Lincoln Avenue, Harvey, 60426
Warren W. Young, 3rd District (1972)
10816 Parnell Avenue, Chicago, 60628 I Fred Z. White, 4th District (1973)
723 North Second St., Chillicothe, 61523 A. Edward Livingston, 5th District (1973)
219 North Main, Bloomington, 61701 J. Mather Pfeiffenberger, 6 District (1972)
State & Wall Streets, Al’on, 62002 Arthur F. Goodyear, 7th District (1973)
142 East Prairie Avenue, Decatur, 62523 Eugene P. Johnson, 8th District (1973)
22 West Main Street, Casey, 62420 Charles K. Wells, 9th District (1972)
117 North 10th Street, Mt. Vernon, 62864 Willard C. Scrivner, 10th District (1972)
4601 State Street, East St, Louis, 62205 Joseph R. O'Donnell, 11th District (1971)
' 444 Park, Glen Ellyn, 60137
Edward W, Cannady, Trustee-at-Large
! 4601 State Street, East St. Louis, 62205
Microfilm copies of current as well as some back issues of the Illinois Aiedical Journal may be purchased from Xerox University Microfilms, 300 SJ. Zeeb Road, Ann Arbor, Mich., 48106.
ABSTRACTS OF BOARD ACTIONS 19
CONVENTION SUMMARY
1970-71 Officers and Hoard ol rriistees 58
Convention Highlights 59
Sunmiary ol House ol Delegates Actions 63
.\ctions on Resohitions _ ....68
CLINICAL ARTICLES
Popliteal .^neurysin: ,\n Uniesolvetl Problem
Richard C. Powers, M.D., F.A.C.S., and Isa Sejdinaj. M.D '^3
Failtire ol Thymectomy in a Six-Year-Old Child with Myasthenia Gravis Chang Hwan Kim, M.D., Bennett R. Sherman, M.D..
and Meyer A. Perlstein, M.D - 44
Evaluation of Hypnotic Eifect of Methacpialone Employing Placebo Responder Elimination
Arpad At massy, M.D 73
Leprosy in Ceylon
Larry D. Greenfield . M.D 87
MEDICAL PROGRESS
Contemjjorai y Practices in Ophthalmology John G. Bellows, M.D., Ph.D 47
SURGICAL GRAND ROUNDS
Lireteral Objtriution 37
FEATURES
Blue Shield Report 1
The President’s Page 11
Clinics lor Crippled Children ,d6
New Phai maceutical Specialties 26
Illinois Medical Assistants .Yssociation 31
Meeting Memos 31
Public Affairs Library _ 43
Editoi ials 55
The View Box 70
Socio-Economic News 81
The Doctor’s Library 84
Obituaries ; .Si 91
(Cover story on fnige 16)
Publications Committee
Jacob E. Reisch. M.D., Chairman Fredric D. Lake, M.D.
Charles K. Wells, M.D Warren W. Young, M.D.
Editoria Board
Harvey Kravitz, M.D. Chairman
Charles Mrozek, M.D. C. J. Mueller, M.D.
Frederick Steigman, M.D. Frederick Stenn, M.D. Arkell M. Vaughn, M.D.
Published monthly by the Illinois Stale :\Iedical Society, 360 N. ^richigan Ave., Chicago. 111., 60601. Copyright 1970. The Illinois State Medical Society.
Subscription $5.00 per year, in advance, postage •repaid, for the United States, Cuba, Puerto Rico, Philippine Islands and Me.vico. $7.50 per year for ill foreign countries included in the Universal Postal •nion. Canada $5.50 U.S. Single current copies .vailable at 7oc.
Second class postage paid at Chicago, 111. and at dditional mailing oftices. When moving please notify
Journal office of new address including old mailing label with notification, if possible. POSTMASTER: Send notice on form No. 3579 to Illinois State Medical Society. 360 N. Michigan Ave., Chicago. 111. 60601.
Pharmaceutical advertising must be approved by the ISMS Publications Committee. Other advertising accepted after review by Publications Committee or Board of Trustees. All copy or plates must reach the •Tournal office by the fifteenth of the month preceding publication. Rates furnished upon request.
Original articles will be considered for publication with the understanding that they are contributed only to the Illinois Medical Journal. The ISMS denies responsibility for opinions and statements expressed by authors or in excerpts, other than editorial or allied views or statements which reflect the authoritative action of the ISMS or of reports on official actions, policies or positions. Views expressed by authors do not necessarily represent those of the Society; any connection with olficial policies is coincidental.
/or Ixtly, 1970
5
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Investment Advisory Service.
Blue Shield Board Members Elected to High AMA Posts
Walter C. Bornemeier, M.D., Chicago, a Trus- tee of Illinois Blue Shield, became the 125th Presi- dent of the American Medical Association and was inaugurated at its annual meeting Wednesday, June 24, in the Grand Ballroom of the Palmer House. Dr. Burtis E. Montgomery, Chairman of the American Medical Association’s Board of Trustees and also a Trustee of Illinois Blue Shield adminis- tered the oath of office.
Dr. Bornemeier has served on the Board of Trus- tees of the Blue Shield Plan of Illinois Medical Service since 1953. In 1963 he was elected Vice- Speaker of the AMA House and was elected Speak- er in 1966.
Burtis E. Montgomery, M.D., Harrisburg, has served on the American Medical Association Board since 1966 and on the Board of Trustees of Blue Shield since 1958. He was President of the Illinois State Medical Society in 1966 and was Chairman of its Board of Trustees from 1958 to 1960.
Dr. Bornemeier, left, and Dr. Montgomery, right, are shown in the above photograph during the inauguration ceremony.
Why Some Blue Shield Claims Are Delayed
A study of Blue Shield claims has been made to determine the reasons why payments have been delayed and to help us make payments to physi- cians more promptly.
The primary cause for delay in Blue Shield pay- ments is due to incomplete information on the Blue Shield Physician’s Service Report form.
In order to speed payments to you, it is necessary for us to have the following infonnation.
On anesthesia claims, please provide the follow- ing information on the Blue Shield claim form.
( a ) The time of the anesthesia
( b ) The charge for anesthesia
( c ) Particular attention should be given to claims submitted for anesthesia administered during a dilation and curettage of the uterus. Please indicate whether the procedure was per- formed for obstetrical purposes. It is sug- gested that you either provide the diagnosis or simply state Dilation and Curettage “ob- stetrical” or “non-obstetrical”. This is neces- sary because of the high volume of claims submitted for this procedure.
On claims submitted for surgical procedures, please include the following information on the Blue Shield Physician’s Service Report form.
(a) Itemization of all charges.
This is particularly important in order to make payment to physicians bn the basis of their Usual and Customary charges for Blue Shield members who are protected by our Usual and Customary program.
(b) When reporting surgical procedures, please do not use such names as, “Strassman proce- dure” or “Nissen procedure”. Payments will be made more promptly if you use standard medical nomenclature.
Claims for radiation therapy are often delayed because the diagnosis is not included on the Physi- cian’s Service Report. By reviewing the claims be- fore they are submitted to Blue Shield unnecessary delay can be prevented and the necessity to contact you or your medical assistant for additional infor- mation can be avoided.
(This is not an advertisement)
ASK BLUE SHIELD
... ABOUT MEDICARE
Services in an Extended Care Facility
Because misunderstandings still exist over pay- ments for services in Extended Care Facilities, we have undertaken a series of articles which began in the May issue of the Illinois Medical Journal to inform Illinois physicians of covered services paid for by Medicare so they will be in a better position to advise their patients that some services may not be covered and alternative financing arrangements may have to be made.
Examples of covered Medicare services in Ex- tended Care Facilities are continued in this report.
Braces and similar devices: — Routine care in connection with such appliances would not con- stitute skilled services. Training in the proper use of a particular appliance should be evaluated in re- lation to the need for physical therapy.
Heat treatments: — The therapeutic use of sun lamps, infrared lamps, diathermy and similar equip- ment constitutes skilled care when:
1. the service is specifically ordered by a physi- cian as part of an active treatment regimen; and
2. the observation by skilled personnel is re- quired in order to evaliiate adequately the results of the treatment and inform the physi- cian of the patient’s progress.
Use of such equipment for palliative purposes or comfort is not a skilled service and would not be a Medicare benefit.
Restraints: — The use of protective restraints such as bed rails, soft binders and supports for wheel chair patients generally does not require the ser- vices of skilled personnel.
Administration of medical gas: — Any regimen re- quiring the administration of medical gases would be started only upon the physician’s order. The initial phase of such a regimen would be skilled care. However, when the administration becomes routine, it would not generally be considered a skilled services because patients can usually be taught to operate their own inhalation equipment.
Restorative nursing: — Restorative nursing proce- dures constitute skilled services when they are pre- scribed by a physician, are designed to restore functions which have been lost or reduced by ill- ness or injury, and are a type whose performance requires the presence of licensed nurses. In many instances, such procedures would be an adjunct to an intensive program of physical therapy.
When a patient has reached his restoration po- tential, the services required to maintain him at this level generally would not constitute skilled nursing care, nor would supervision of exercises which have been taught to the patient be consid- ered skilled services.
Physical therapy, one aspect of restorative care, consists of the application of a complex and sophis- ticated group of physical modalities and therapeutic services. Physical therapy, therefore, is a skilled service. Because the statute defines extended care as skilled nursing care on a continuing basis, pro- vision of physical therapy only would not justify a finding that the patient requires extended care. In some situations, a patient whose primary need is for physical therapy will also require sufficient skilled nursing to meet the definition of extended care. The need for such supportive skilled nursing on a continuing basis may be presumed when:
1. the therapy is directed by the physician who determines the need for therapy, the capacity and tolerance of the patient, and the treatment objectives; and
2. the physician, in consultation with the ther- apist, prescribes the specific modalities to be used and frequency of therapy services; and
3. the therapy is rendered by or under the su- pervision of a physical therapist who meets the qualifications established by regulations; when the qualified therapist is the supervisor, he is available and on the premises of the fa- cility while the therapy is being given, he makes regular and frequent evaluations of the patient, records findings on the patient’s chart, and communicates with the physician as in- dicated; and
4. the therapy is for the restoration of a lost or impaired function. For example, frequent physical therapy treatments in connection with a fractured back or hip or a CVA can be presumed to be directed toward restoration of lost or impaired function during the early phase — when physical therapy can be pre- sumed to be effective. However, when the condition has been stabilized, the presumption that continuing supportive skilled nursing ser- vices are required is no longer valid. Such cases must be evaluated in relation to the spe- cific amount of skilled nursing attention re- quired in the individual case and supported by the physician’s orders and nursing notes.
The discussion of services in extended care facili- ties will be continued in the next issue of this re- port.
Notice of changes in Certification
The Social Security Administration has announced that Medicare can reimburse for selected laboratory procedures performed by the following laboratory: Colton Microbiology Laboratory 555 North Monroe Hinsdale, Illinois 60521
CThis is not an advertisement)
J. Ernest Breed
Tlie
President’s
Page
Responsibility
The responsibility lor the health of all the people in the United States is still the privilege of the American medical proles- sion, but, as the problems become more complex, others loudly proclaim the need for a change in management. The difficul- ties we face are profound— the increasing cost, the increasing number of recjuired services, the need for increasing numbers of assistants with diverse skills, the declara- tion of health care as a right, the increas- ing demands by those previously unin- formed as they learn health for them is possible, the fractionation of the profession into specialties and sidjspecialties— all of these and many other factors compound our problem. Of course, if we wish to abdicate, others would be glad to relieve us of con- trol over the health team.
Since few of us woidd forsake our call- ing, we in the Medical Society plan to pro- ceed in all manners possible to discharge our responsibilities to the public.
As outlined in my inaugural address, four areas require priority in our immediate activities.
In Continuing Education we plan to cooperate with the University of Illinois and other schools to establish the most feasible methods to assist physicians in keeping up with the rapid changes in scien- tific knowledge. We also hope to place em- phasis on the “art” of medicine, since it does little good to have the correct diag-
nosis if the patient refuses to accept it or the prescribed treatment.
Peer Review not only is necessary as a third party reepurement, but it serves as a subconscious stimulant to keep members abreast of new techni(jues. It also serves as a guarantee of quality care for the patient and protects the physicians from unjust accusations.
Malpractice claim increases require a defensive crash program which we hope to inaugurate soon. It involves the provision of a panel of experts for screening threat- ened suits. It is hoped this procedure will fractionate the number of claims.
Changes In the Health Care Delivery System are designed to take advantage of modern, efficient business methods, the use of allied health assistants, computers, mod- ern methods of communication, etc. You will hear much more of this later, but it is obvious to all that adequate numbers of young general practitioners required to replace our rapidly retiring older family physicians are just not going to be available.
If we are going to discharge the resjDon- sibilities as guardians of the public health then we must be realistic and adopt tech- nical changes in the delivery of health care that will permit us to do the job.
for July, 1970
Newsreel Classics
By M. W. Martin/Ohio
“The death of the patient terminates the physician-patient relationship.”
Ohio State Medical Journal "First draft call for sex comes to women doctors.”
Russellville Courier-Deinocrat “As to the heart condition, a result of the accident, Dr. Stahl stated that while she will probably always have this ailment, it will not, in his opinion, always be perman- ent.”
Hut ch i ns on Neivs-Herald “Mr. Ringling eats sparingly; smokes de- nicotinized cigars, takes daily exercises and until the beginning of this illness was able to touch the floor with his finger tips with- out bending.”
New York Times “ ‘But,’ Dr. Harrison says, ‘we’re happy to get cadavers at any price and we’ll settle for a change in legislature that will help to maintain an adequate supply.’ ”
Norway Advertiser “William Sorensen returned home yes- terday from the hospital, where his left leg was placed in a cast following a fracture of the right ankle.”
Auburn Star
“I’he bandits demanded heavy ransom for their release, threatening to cut off their heads and then put them to death if the money was not forthcoming.”
T oledo Blade
“I'he district has no figures as to the number of married students who are preg- nant. Almost all of them are girls.”
Jackson State Times “Miami man admits taking his own life.”
Oakland Tribune “His face still patched with adhesive plaster, Winston Churchill today was taken to the Waldorf Astoria Hotel and was im- mediately put to bed under his nurse and with his wife and daughter.”
Genesee Livingston-Republican “A sixty-five-year-old male with proven eosinophilic gastroenteritis was followed for nearly seven years.”
JAMA
“City youths brought to county jail fol- lowing post-mortem statement of dead bandit.”
Chicago Tribune
12
Brief Summary of Prescribing Information—
9-9/22/69. For complete information consult Official Package Circular.
Indications: Essential hypertension. Use cau- tiously in patients with renal insufficiency, particularly if they are digitalized. Contraindications: Anuria, oliguria, active peptic ulceration, ulcerative colitis, severe de- pression or hypersensitivity to its components contraindicates the use of Salutensin. Warnings: Small-bowel lesions (obstruction, hemorrhage, perforation and death) have occurred during therapy with enteric-coated formulations containing potassium, with or without thiazides. Such potassium formula- tions should be used with Salutensin only when indicated and should be discontinued immediately if abdominal pain, distension, nausea, vomiting or gastrointestinal bleeding occurs. Use cautiously, and only when deemed essential, in fertile, pregnant or lactating pa- tients. Use in Pregnancy: Thiazides cross the placenta and can cause fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism and possibly electrolyte disturbances. Fatal reactions may occur with reserpine during electroshock therapy; discontinue Salutensin 2 weeks be- fore such therapy. Increased respiratory secretions, nasal congestion, cyanosis and anorexia may occur in infants born to reser- pine-treated mothers.
Precautions: Azotemia, hypochloremia, hypo- natremia, hypochloremic dkalosis and hypo- kaliemia (especially with hepatic cirrhosis and corticosteroid therapy) may occur, par- ticularly with pre-existing vomiting and diar- rhea. Potassium loss or protoveratrine A may cause digitalis intoxication. Potassium loss responds to potassium-rich foods, potassium chloride or, if necessary, discontinuation of therapy. Stop therapy if protoveratrine A induces digitalis intoxication. Serum am- monia elevation may precipitate coma in precomatose hepatic cirrhotics. Discontinue therapy 2 weeks before surgery or if myo- cardial irritability, progressive azotemia or severe depression occur. Exercise caution in patients with chronic uremia, angina pec- toris, coronary thrombosis or extensive cere- bral vascular disease or bronchial asthma and in those with a history of peptic ulceration or bronchial asthma; in post-sympathectomy pa- tients; in patients on quinidine; and in pa- tients with gallstones, in whom biliary colic may occur. Patients who have diabetes mellitus or who are suspected of being pre- diabetic should be kept under close observa- tion if treated with this agent.
Adverse Reactions: Hydroflumethiazide; Skin rashes (including exfoliative dermatitis), skin photosensitivity, urticaria, necrotizing angiitis, xanthopsia, granulocytopenia, aplastic anemia, orthostatic hypotension (potentiated with alcohol, barbiturates or narcotics), aller- gic glomerulonephritis, acute pancreatitis, liver involvement (intrahepatic cholestatic jaundice), purpura plus or minus throm- bocytopenia, hyperuricemia, hyperglycemia, glycosuria, malaise, weakness, dizziness, fa- tigue, paresthesias, muscle cramps, skin rash, epigastric distress, vomiting, diarrhea and constipation. Reserpine: Depression, peptic ulceration, diarrhea. Parkinsonism, nasal stuf- finess, dryness of the mouth, weight gain, impotence or decreased libido, conjunctival injection, dull sensorium, deafness, glaucoma, uveitis, optic atrophy, and, with overdosage, agitation, insomnia and nightmares. Proto- veratrine A: Nausea, vomiting, cardiac ar- rhythmia, prostration, blurring vision, mental confusion, excessive hypotension and brady- cardia. (Treat bradycardia with atropine and hypotension with vasopressors.)
Usual Dose: 1 tablet b.i.d.
Supplied: Bottles of 60, 600, and 1000 scored 50 mg. tablets.
Salutensin'
hydroflumethiazide, 50 mg./ reserpine, 0.125 mg. protoveratrine A, 0.2 mg.
BRISTOL LABORATORIES Division of Bristol-Myers Company Syracuse, New York 13201
BRISTOL
ther days she doesn't even try
I the treatment of depression, Aventyl HCI as part of your total srapy often brings early symptomatic improvement, entyl HCI aids in renewing motor function and increasing erest in life. Patients may report that they eat more, enjoy idisturbed sleep . , . generally begin to function better. Relief m their most distressing symptoms helps them “open up” id ventilate their problems.
|i depression
^VtNTYL' HCI
ORTRIPTYLINE HVDROCHLORIDE
lations; Aventyl HCI is indicated for the relief of toms of depression. Endogenous depressions are more to be alleviated than are other depressive states.
raindications: The use of Aventyl HCI or other tri- antidepressants concurrently with a monoamineoxi- (M AO) inhibitor is contraindicated. Hyperpyretic crises, e convulsions, and fatalities have occurred when simi- cyclic antidepressants were used in such combinations, ntinue the MAO inhibitor for at least two weeks before jnent with Aventyl HCI. Patients hypersensitive to ityl HCI should not be given the drug.
3ss-sensitivity between Aventyl HCI and other diben- lines is a possibility.
entyl HCI is contraindicated during the acute recovery ti after myocardial infarction.
jings: Cardiovascular patients should be supervised ly because of the tendency of Aventyl HCI to produce i tachycardia and to prolong the conduction time, ardial infarction, arrhythmia, and strokes have oc- d. The antihypertensive action of guanethidine and ar agents may be blocked. Because of its anticholinergic ity, Aventyl HCI should be used with great caution in nts with glaucoma or a history of urinary retention, nts with a history of seizures should be followed ly, since this drug is known to lower the convulsive hold. Great care is required if Aventyl HCI is admin- ;d to hyperthyroid patients or to those receiving thy- medication, since cardiac arrhythmias may develop. ;age in Pregnancy — Safe use of Aventyl HCI ig pregnancy and lactation has not been established; Tore, the potential benefits of administration to preg- patients, nursing mothers, or women of childbearing itial must be weighed against the possible hazards, rage in Children— l'n\% drug is not recommended ise in children, since safety and effectiveness in the itric age group have not been established, entyl HCI may impair the mental and/or physical ;ies required tor the performance of hazardous tasks, as operating machinery or driving a car; therefore, latient should be warned accordingly.
autions: Aventyl HCI in schizophrenic patients may t in an exacerbation of the psychosis or may activate t schizophrenic symptoms. In overactive or agitated nts, increased anxiety and agitation may occur. In c-depressive patients, Aventyl HCI may cause symp- of the manic phase to emerge, oublesome patient hostility may be aroused by the use ventyl HCI. Epileptiform seizures may accompany its inistration, as is true of other drugs of its class.
Close supervision and careful adjustment of the dosage are required when Aventyl HCI is used with other anti- cholinergic drugs and sympathomimetic drugs.
The patient should be informed that the response to alcohol may be exaggerated.
When necessary, the drug may be administered with electroconvulsive therapy, although the hazards may be increased. Discontinue the drug for several days, if possible, prior to elective surgery.
Because the possibility of a suicidal attempt by depressed patients remains after the initiation of treatment, dispense the least possible quantity of drug at any given time.
Both elevation and lowering of blood sugar levels have been reported.
Adverse Reactions: Note; Included in the following list are a few adverse reactions which have not been reported with this specific drug. However, the pharmacologic simi- larities among the tricyclic antidepressant drugs require that each of the reactions be considered when nortriptyline is administered.
Carc//ovascu/ar— Hypotension, hypertension, tachycar- dia, palpitation, myocardial infarction, arrhythmias, heart block, stroke.
Psycfi/afr/c— Confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anx- iety, restlessness, agitation; insomnia, panic, and night- mares; hypomania; exacerbation of psychosis.
A/euro/og/ca/— Numbness, tingling, paresthesias of extremities; in-co-ordination, ataxia, tremors; peripheral neuropathy; extrapyramidal symptoms; seizures, alteration in EEG patterns; tinnitus.
Anticholinergic— Diy mouth and, rarely, associated sublingual adenitis; blurred vision, disturbance of accom- modation, mydriasis; constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract.
Allergic— SWin rash, petechiae, urticaria, itching, photo- sensitization (avoid excessive exposure to sunlight); edema (general or of face and tongue), drug fever, cross-sensitivity with other tricyclic drugs.
Hemafo/og/c— Bone-marrow depression, including agranulocytosis; eosinophilia; purpura; thrombocytopenia.
Gastro-Intestinal— Nausea and vomiting, anorexia, epigastric distress, diarrhea; peculiar taste, stomatitis, ab- dominal cramps, blacktongue.
Endocrine— Gynecomastia in the male; breast enlarge- ment and galactorrhea in the female; increased or de- creased libido, impotence; testicular swelling; elevation or depression of blood sugar levels.
Of/ier— Jaundice (simulating obstructive); altered liver function ; weight gain or loss; perspiration ; flushing; urinary
Additional information available upon request.
ELI LILLY AND COMPANY* INDIANAPOLIS, INDIANA 46206
frequency, nocturia; drowsiness, dizziness, weakness, and fatigue; headache; parotid swelling; alopecia.
Withdrawal Symptoms— Though these are not indic- ative of addiction, abrupt cessation of treatment after pro- longed therapy may produce nausea, headache, and malaise.
Administration and Dosage: Aventyl HCI is not recom- mended for children.
Aventyl HCI is administered orally in the form of Pul- vules® or liquid. Lower dosages are recommended for elderly patients, adolescents, and outpatients not under close supervision. .Start dosage at a low level and increase gradually, noting carefully the clinical response and any evidence of intolerance. Eollowing remission, maintenance medication may be required for a prolonged period at the lowest effective dose.
If a patient develops minor side-effects, reduce the dosage. Discontinue the drug promptly if serious adverse effects or allergic manifestations occur.
Usual Adult Dose— 25 mg. three or four times daily, starting at a low level and increasing as required. Doses above 100 mg. per day are not recommended.
Elderly and Adolescent Patients— 20 to 50 mg. per day, in divided doses.
Overdosage: Toxic overdosage may result in confusion, restlessness, agitation, vomiting, hyperpyrexia, muscle rigidity, hyperactive reflexes, tachycardia, EGG evidence of impaired conduction, shock, congestive heart failure, stupor, coma, and C.N.S. stimulation with convulsions followed by respiratory depression. Deaths have occurred following overdosage with drugs of this class.
No specific antidote is known. General supportive meas- ures are indicated, with gastric lavage. Respiratory assist- ance is apparently the most effective measure when indi- cated. The use of C.N.S. depressants may worsen the prognosis.
Barbiturates for control of convulsions alleviate an in- crease in the cardiac work load but should be used with caution to avoid potentiation of respiratory depression.
Intramuscular paraldehyde or, preferably, diazepam pro- vides anticonvulsant activity with less respiratory depres- sion than do the barbiturates.
Digitalis and/or pyridostigmine may be considered in serious cardiovascular abnormalities or cardiac failure.
The value of dialysis has not been established.
How Supplied: Liquid Aventyl® HCI (nortriptyline hydro- chloride, Lilly), 10 mg. (equivalent to base) per 5 ml., in pint bottles.
Pulvules Aventyl HCI, 10 and 25 mg. (equivalent to base), in bottles of 100 and 500. [040670]
Clinics for Crippled
I'wenty clinics lor Illinois’ physically handicapped children have been schednled for August by the University of Illinois, Division of Services lor Crippled Children. The Division will hold 14 general clinics provitling diagnostic orthopedic, pediatric, speech and hearing examinations along with medical social, and nursing service. There will be hve sjrecial clinics lor chil- dren with cardiac conditions and rheumatit level, and one for children with cerebral palsy. Clinicians are selected from among private physicians who are certihed Board members. Any private physician may refer to or liring to a convenient clinic any child or children for whom he may want exami nation or consultative services.
.Vugust 5— Carlinville— Carlinville Area Hospital
.Vugust 5— Hinsdale— Hinsdale Sanitarium Vugust (i— Lake County Cardiac— V^ictory Memorial Hospital
Vugust I I —Peoria— St. Francis Cihildrcn’s Hosjtital
Vugust II— East St. Louis— C;hristian Wel- fare Hosjrital
.Vugust 1 2— Champa ign-Urbana— McKinley Hospital
.Vugust I 3— Springfield General— St. John’s Hosjjital
.Vugust 14— Chicago Heights Cardiac— St. fames Hospital
■ Vugust 1 8— Belleville— St. Elizabeth’s Hos-
pital
Vugust 18— Rock Island Area General- Mo- line Public Hosjjital
■ Vugust 19— Chicago Heights General- St.
James Hospital
Children Scheduled
Auaiist 20— Rockford— Rockford Memoiial Hospital
August 20— Bloomington— St. Joseph’s Hos- pital
August 20— Elndunst Cardiac — Memorial Hospital of DuPage County August 24— Peoria C a r d i a c— St. Francis Children’s Hospital
August 25— Peoria— St. Francis Children’s
o
Hospital
August 26— Aurora— Co|)ley Memorial Flos- pital
■ Vugust 26— Springfield Pediatric Neurology
—Diocesan Center
■Vugust 28— Chicago Heights Cardiac— St. James Hospital
■ Vugust 28— Evanston— St. Erancis Hos]htal
The Division of Services lor Crippled Children is the official state agency estafi- lishcd to pros ide medical, surgical, correc- tive, ami other .services and facilities for diagnosis, hospitalization and alter-care for children with crippling conditions or svho are suflering from conditions th;it may lead to crippling.
In carrying on its program, the Division works cooperatively with local medical so- cieties, hospitals, the Illinois Children’s Hos- pital-School, civic anti Iraternal clubs, visit- ing nurse tissociation, local social and svel- fare agencies, local chapters of the National Foundation and other interestetl groups. In all cases, the work of the Division is intend- ed to extend and supplement, not supplant activities of other agencies, either public or private, state or local, carried on in behalf of crip|jled children.
ON THE COVER
The expansion of medicine in terms of health care and knowledge is expressed in the bril- liant colors surrounding the caduceus, which like the rays of the sun appear to be far-reaching, blending into the unknown.
The caduceus long recognized as the symbol of medicine consists of a staff of Aesculapius about which a single serpent is coiled.
The Medical Corps of the United States Army has modified the symbol to consist of a staff with two formal wings at the top, and two separate serpents entwined about the remainder. The latter is not regarded as a medical, but as an administrative emblem, implying neutral, non-combatant status.
16
Illinois Medical Journal
Abstracts Of Board Actions
Board of Trustees Meeting During Annual Convention May 16-20, 1970 Sherman House Hotel, Chicago
These abstracts are published so that rnembers of the Illinois State Medical Society may keep advised of the actions of the Board of Trustees. It covers only major actions and is not intended as a detailed report. Full minutes of the meetings are available upon any member’s request to the headquarters office of the ISMS.
Agreement with Third Party Carrier
Progress was reported by Dr. Edward Cannady in discussions with the Continental Casualty Company, regarding administration of Part B Medicare in 97 Illinois counties. The following agree- ments have been reached:
Inconsistencies of charges will be examined by the company and elimination of coding inconsistencies will be accomplished ; form letters written to pa- tients by the firm will be discussed with ISMS to eliminate obnoxious phrases ; telephone calls to physicians will be curtailed as much as possible ; physicians will be given opportunity to justify questioned bills.
Continuing Medical Education
Previous action of the Board of Trustees, requesting the House of Delegates to authorize a $20 per member dues assessment in support of the continuing medical education program, was re- considered. The action was based on information from Dr. George Miller, University of Illinois, that other medical schools would not be participants and that the program will largely be conducted by the University of Illinois. The Board will recom- mend, to the House of Delegates, enthusiastic support of the program, with ISMS participation, but financial support from ISMS will be deferred until a later date.
IMPAC Membership Records
The report of the treasurer showed that dues paying members recorded for the first quarter of 1970 totaled 8,304. Of these members, 44% had become contributors to IMPAC on a voluntary basis. The IMPAC 3rd District percentage was 36% and the re- mainder of the state 62% of the paid membership. The anticipated total paid members of the ISMS for the year is 9,350. Retired, emeritus and other categories will increase the total membership to about 10,500.
Meeting with Illinois Hospital Association
At a meeting between the Executive Committees of the ISMS and IHA it was agreed —
•to jointly update a handbook on the release of medi- cal records previously published by the Illinois Medical Records Librarian Association •to send a joint letter to hospitals, E.C.F.'s and
ly
for July, 1970
nursing homes regarding the proper use of physical therapy services
©to jointly study ways of reducing malpractice cases •that IHA Executive Committee would distribute a letter to hospitals stating the Association's of- ficial position on physicians serving on hospital boards
• that the ISMS would keep the IHA informed of new de- velopments in the use of physicians' assistants
CMS Funds for Benevolence Core
All recipients of ISMS benevolence from the 3rd District will be paid from a fund at CMS, established at the bequest of one of the past presidents of the State Society Auxiliary. This pro- cedure will be followed after July 1, 1970, and continue as long as funds are available from this source. Payments to most of the benevolence recipients will be increased effective July 1, 1970.
School Bus Driver Physicals
Many school districts, under existing local option, do not require physical examinations for school bus drivers. The Board acted to refer this matter to the Committee on Public Safety for study and recommendations for subsequent action.
Peer Review Guidelines
The Board reviewed further refinements made in the Peer Re- \ iew Guidelines by the interim peer review committee. Several changes in wording were suggested. The Guidelines will be pub- lished in final form and be distributed to county societies for their advice and guidance.
Annual Illinois Luncheon Cancelled
The ISMS will participate in honoring Dr. Walter C. Bornemeier as the in-coming President of the American Medical Association. The funds usually expended on the Illinois luncheon at the AMA meeting will be made available to assist in hosting the recep- tion honoring Dr. Bornemeier on Wednesday evening, June 24. The reception will follow the inaugural services.
New Chairman of the Board Elected
At the post-convention Board meeting. Dr. Willard C. Scrivner, East St. Louis, was selected to follow Dr. Frank J. Jirka, Jr., River Forest, as Chairman of the Board. Dr. Edward W. Cannady, immediate past president was named to serve as Parliamentarian for the Board of Trustees.
Computerized Billing Service Approved
Upon recommendation of the Council on Economics and Govern- mental Health Programs, the computerized billing system for physicians, developed by Indecon, a Chicago based firm, was en- dorsed. Physicians who subscribe to this service will be invited to share fee data with the Council on Peer Review. Indecon is headed by Mr. William Love, formerly associated with Blue Shield.
(CoJitimwd on pnge 86)
20
Illinois Medical Journal
^chrocidin Tablets and Syrup
etracycline HCl— Antihistamine— Analgesic Compound
ach tablet contains: ACHROMYCIN® Tetracycline HCl 125 mg.; Phenacetin 120 mg.; Caffeine 30 mg.; Salicylamide 150 mg.; Chlorothen Citrate 25 mg.
CHROCIDIN Tetracycline HCl— Antihistamine— Analgesic Compound Tablets and Syrup are recommended for the treatment P tetracycline-sensitive bacterial infection vyhich may complicate vasomotor rhinitis, sinusitis and other allergic diseases of the pper respiratory tract, and for the concomitant symptomatic relief of headache and nasal congestion. For children and elderly atients you may prefer caffeine-free ACHROCIDIN Syrup. Each 5 cc contains: ACHROMYCIN Tetracycline equivalent to etracycline HCl 125 mg.; Phenacetin 120 mg.; Salicylamide 150 mg.; Ascorbic Acid (C) 25 mg.; Pyrilamine Maleate 15 mg.
onlraindications: Hypersensitivity to any imponent.
'arning: In renal impairment, since liver tox- ity is possible, lower doses are indicated; dur- ig prolonged therapy consider serum level terminations. Photodynamic reaction to sun- ght may occur in hypersensitive persons, iiotosensitive individuals should avoid expo- ire; discontinue treatment if skin discomfort :curs.
recautions: Drowsiness, anorexia, slight gas- ic distress can occur. In excessive drowsi- :ss, consider longer dosage intervals. Persons
on full dosage should not operate vehicles. Nonsusceptible organisms may overgrow; treat superinfection appropriately. Treat beta- hemolytic streptococcal infections at least 10 days to help prevent rheumatic fever or acute glomerulonephritis. Tetracycline may form a stable calcium complex in bone-forming tissue and may cause dental staining during tooth development (last half of pregnancy, neonatal period, infancy, early childhood).
Adverse Reactions: Gastrointestinal— anore'x.ia, nausea, vomiting, diarrhea, stomatitis, glossi- tis, enterocolitis, pruritus ani. 5km— maculo-
papular and erythematous rashes; exfoliative dermatitis; photosensitivity; onycholysis, nail discoloration. dose-related rise in
BUN. Hypersensitivity reactions— unicatia, angioneurotic edema, anaphylaxis. Intracranial —bulging fontanels in young infants. Teeth— yellow-brown staining; enamel hypoplasia. B/ooif— anemia, thrombocytopenic purpura, neutropenia, eosinophilia. Liver- cholestasis at high dosage.
Upon adverse reaction, stop medication and treat appropriately.
LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 10965
534-9
NEW
PHARMACEUTICAL
SPECIALTIES
by Paul deHaen
For detailed information regarding indica- tions, dosage, contraindications, and adverse reactions, refer to the manufacturer’s package insert or brochure.
Single Chemicals: Drugs not previously known, including new salts.
Duplicate Single Products: Drugs marketed by more than one manufacturer.
Combination Products: Drugs consisting of two or more active ingredients.
New Dosage Forms: Of a previously introduced product.
A New Drug Application has been granted by the U.S. Food and Drug Administration for the following new drugs.
CORTROSYN Hormones-Corticoids
Manufacturer: Organon
Nonproprietary Name: Cosyntropin (USAN)
DALMANE Sedative & Hypnotic-Nonbarbiturate
Manufacturer: Roche
Nonproprietary Name: Flurazepam HCl
MIRTHRACIN Cancer Chemotherapy Manufacturer: Pfizer
Nonproprietary Name: Mirthramycin (USAN) The following new drugs have been marketed:
NEW SINGLE CHEMICALS ESKALITH
Manufacturer: Smith Kline & French LITHANE
Manufacturer: Roerig, Div. Pfizer
LITHONATE
Manufacturer: Rowell
Nonproprietary Name: Lithium carbonate: Ata- raxic, Psychostimulant R
Indications: Control of manic episodes in manic depressive psychosis.
Contraindications: Significant cardiovascular or renal disease, or evidence of brain damage. Do not administer to children under 12.
Dosage: Acute mania: 600 mg. t.i.d.; long term: 300 mg. t.i.d. Individualize according to serum levels and clinical response.
Supplied: Capsules or tablets, 300 mg.
KETAJECT Manufacturer: Bristol KETALAR
Manufacturer: Parke, Davis (Originator) Nonproprietary Name: Ketamine HCl: Anestbe- tic-Injectable R
Indications: Sole short acting anesthetic agent for diagnostic and surgical procedures. Can be extended for periods of six hours or longer. Contraindications: History of cerebrovascular ac- cident or hypersensitivity to the drug.
Dosage: Individualized according to patient’s re- quirements.
Supplied: Vials, 20 cc containing 10 mg. base/cc 50 cc containing 10 mg. base/cc 10 cc containing 50 mg. base/cc
NEW INDICATION
Xylocaine Antiarrhythmic R
Manufacturer: Astra
Nonproprietary Name: Lidocaine (USAN) Indications: Acute and life-threatening arrhyth- mias.
Contraindications: Hypersensitivity to local anes- thetics of the amide type. Adams-Stokes syn- drome and severe degrees of sinoatrial, atrio- ventricular or intraventricular block.
Dosage: Usual dose: 50-100 mg. intravenously under ECG monitoring administered at ap- proximately 25-50 mg. /min.
Supplied: Single dose ampules of 2% solution, 5 and 50 cc. Special package for arrhythmias.
DUPLICATE SINGLE PRODUCTS CENDEVAX Biological R
Manufacturer: Recherche et Industrie Therapeu- tiques, subsidiary of Smith Kline & French Nonproprietary Name: Rubella virus vaccine, live (Cendehill Strain)
Indications: Immunization against German meas- les.
Contraindications: Febrile illness, leukemia,
lymphoma, generalized malignancy or lowered resistance due to therapy with corticosteroids, alkylating drugs, antimetabolites or radiation. Hypersensitivity to rabbits or neomycin. Do not administer to pregnant women.
Dosage: Injection, s.c. only — 0.5 cc.
Supplied: Vials, single dose.
ETHAQUIN Vasodilators-Peripheral R
Manufacturer: Ascher Nonproprietary Name: Ethaverine HCl Indications: Peripheral and cerebral vascular in- sufficiency associated with arterial spasm; smooth muscle spasmolytic in spastic condi- tions of the G.I. and G.U. tract. Contraindications: Presence of complete atrio- ventricular dissociation.
Dosage: 1 tablet t.i.d.
Supplied: Tablets, 100 mg.
FEMINONE Estrogen R
Manufacturer: Upjohn Nonproprietary Name: Ethinyl estradiol Indications: Hypoestrogenic states. Contraindications: Known or suspected malig- nancy of breast or genital organs. Undiagnosed vaginal bleeding. Liver dysfunction or disease. Thrombophlebitis or history of thrombophle- bitis or pulmonary embolism. History of cere- brovascular accident.
Dosage: Individualized. Va to 3 tablets t.i.d. Supplied: Tablets, 0.05 mg.
OXY-KESSO-TETRA Antibiotic R
Manufacturer: McKesson, Div. Formost-McKes- son
Nonproprietary Name: Oxytetracycline HCl Indications: Variety of systemic infections, cer- tain infections of the respiratory tract, skin and soft tissues, gastrointestinal and genito- urinary tract, due to susceptible organisms. Contraindications: Hypersensitivity to tetracy- cline.
Dosage: Adults: 250-500 mg. q.i.d.
Children: As per instructions.
Supplied: Tablets, 250 mg.
SOSOL Sulfonamides R
Manufacturer: McKesson, Div. Foremost-McKes- son
Nonproprietary Name: Sulfisoxazole
(Contimied on page 42)
26
Illinois Medical Journal
ILLINOIS
MEDICAL
ASSISTANTS
ASSOCIATION
REPORT
Today’s Challenge: Medicine
By Thelma Peplow/Sycamore
Keeping abreast of the fast pace in the new and ever-changing field of medicine is a challenge, not only to the physician, but also to the medical assistant. In this age of computers and other new diagnostic and therapeutic methods, the assistant must be able to cope with the changing times. A program of continuing education is the only answer in enabling us to meet our daily work crises.
The Illinois Medical Assistants Associa- tion’s aim is to educate its members so they can be part of the medical team, thereby improving the relationship between the physician, patient and assistant. Local Medi- cal Assistant Chapters use educational lec- tures, films and panel discussions to keep the members alert to the many problems with which they may be confronted in their jobs. These programs encompass the varied duties of the medical assistant, such as col- lections, telephone technique, and office and clinical procedures.
The sole purpose of the Medical Assist- ants Association is to continue our educa-
tion by reviewing the old and learning the new. Our organization is a non-union, non- profit association, dedicated to better serv- ice to the medical profession and to the public.
To have an alert mind, one must keep learning. To have the desire to learn, one should not falter, but be persistant in pur- suing the opportunities available. Living in our modern world of acceleration, fur- ther education is a necessity. Along with improving our work, we can also learn to understand the needs of our fellowman. This all adds not only to the education, but also to the dedication of the Medical Assistant.
If your assistant is interested in self im- provement, she may contact:
Mrs. Norma Domanic, 1st Vice President 150 Ash Street New Lennox, 111. 60451 or
Mrs. Vivian Kraft, 2nd Vice President R. R. #2
Normal, 111. 61761
Meeting Memos
July 25-August 15 — Polytechnic Insti- tute of Brooklyn
Three week summer course in Research Instrumen- tation
333 Jay Street, Brooklyn, New York
July 27-August 9 — U.S. Department of Health, Education and Welfare
Summer Institute in Suicidology
National Institute of Mental Health, Washington,
D.C.
August 12-15 — The American Academy of General Practice Fourth World Conference on General Practice Palmer House Hotel. Chicago August 16-21 — American Academy of Physical Medicine and Rehabilitation J2nd Annual Assembly New York Hilton, New York August 16-21 — American Congress of
Rehabilitation Medicine
47th Annual Session
New York Hilton, New York
August 17-21 — Western Institute of
Drug Problems
Third Annual Summer School
Portland State University, Portland, Oregon
August 19-23— UCLA
Advanced Seminar in Urology
Residential Conference Center, Lake Arrowhead,
California
August 20-22 — University of Wisconsin
Ninth National Conference on Therapies for Ad- vanced Cancers
University of Wisconsin, Madison
August 23-28 — International Diabetes Federation
7th International Congress of Diabetes Buenos Aires, Argentina
for July, 1970
31
Now
available for your prescribing
32
Illinois Medical Journal
Illinois Medical Journal
volume 138, number 1
July, 1970
Popliteal Aneurysm:
An Unresolved Problem
By Richard C. Powers^ M.D., F.A.C.S., and Isa Sejdinaj, M.D., F.A.C.S./Elgin
In 1918, at the beginning ol the era ol direct vascidar surgery, Linton^ reported 100% limb survival in a series ol 13 popli- teal aneurysms treated by preliminary lum- bar sympathectomy lollowed by aneurys- mectomy. In a review of the literature, the authors were unable to find a comparably good series reported since that time. How- ever, careful analysis ol this frequently quoted report confirms that no aneury,sm was thrombosed preojreratively and all pa- tients had at least one intact foot pidse at the time of surgery. As recently as 1966,
Richard C. Powers, M.D, (left), is attend- ing surgeon in vascular surgery, Sherman and St. Joseph Hospi- tals, Elgin. He is a graduate of the Northwest- ern University Medical School and served his internship in Evanston Hospital and a residency at Hines V.A. Hospital. Isa Sejdinaj, M.D. (right) is a graduate of the University of Graz, Austria, Medical School. He also is attending surgeon in vascular surgery at Sherman and St. Joseph Hospitals.
Baird- reported continuing failure with the .surgical treatment of thrombosed popliteal aneurysm and that “amputation was nece,s- sary in hall of the thrombosed aneurysms.” Janes'^ reviewed 100 cases of popliteal an- eurysm in 1952, treated and untreated, and concluded that “it is debatable whether there is anything to gain by operating on a ]jopliteal aneurysm which has been com- pletely occluded by a thrombus.” I'his con- clusion led to his recommendation that sur- gical consideration be given to the treat- ment of popliteal aneurysm prior to de- velopment of thrombosis. A decade later, 1962, the same author reported that 50% of thrombosed aneurysms in his series still resulted in amputation. In the same era DeBakey’s group'’ and Julian’s groipF’ re- viewed similar problems in their series. Hara and Thompson’ reported amputation ol 10 of 18 limbs after acute occlusion, in 1966, again approximating a 50% limb-loss rate. Our personal series, treated in a com- munity hospital, is small, but further em- phasizes that thrombosis of popliteal an- eurysm is catastrophic.
Case Reports
Case 1. A 58-year-old salesman was re- ferred with a 21 hour history of the exist-
for July, 1970
33
Fig. 1
ence of a cold, painful, pulseless foot. His past history was positive for diabetes melli- tus and prior coronary thrombosis. Physical examination was negative excejrt for the above findings, the presence of a tender lump in the right popliteal space, and the presence of a non-tender pulsatile mass iu the left popliteal space.
Primary resection of a thrombosed popli- teal aneurysm with prosthetic grafting was done 3-4-59. The graft was successful, with return of all peripheral pidses and no resid- ual ischemic compartment.
Two years later the patient expired of recurrent coronary thrombosis; autopsy confirmed a patent graft.
Case 2. A 71-year-old insurance adjuster was referred four days after development unilaterally of a cold, white, painful foot. Past history added nothing, and the physi- cal findings were only as described. Femoral angiography confirmed a thrombosed pop- liteal aneurysm, with minimal collateral circulation. Emergency resection of the aneurysm, with primary prosthetic grafting, was done 6-22-61. Anterior compartment changes were irreversible, and above-knee amputation followed on 6-25-61. Figure 1 illustrates this long, fusiform aneurysm.
Five years later he was referred again, with a similar history regarding the re- maining extremity, in spite of a warning that he should seek prompt care in such an instance. Femoral arteriogram con- firmed a thrombosed popliteal aneurysm. This time, lumbar sympathectomy was done, with limb survival. No rest pain re- sulted; the patient has a useful extremity two years later.
Case 3. On 9-3-63, a 58-year-old factory employee presented with a 30 hour history of a cold, white foot. Emergency femoral angiography confirmed a thrombosed pop- liteal aneurysm, and this was resected and grafted the same day. Irreversible changes tvere present and below-knee amputation eventuated. Figure 2 shows a series of berry- like lesions, impossible to feel in the popli- teal space.
On 3-2-66, three years later, an almost identical sequence occurred, involving the opposite extremity. The single variation was that the amputation was above-knee. The patient remains a bilateral amputee, aged 62, with limiting coronary artery tlisease.
Case 4. A 54-year-old outdoor workman was referred because of a painful, pulsating jjopliteal mass. Distal pulses were strong. On 11-3-64, the popliteal aneurysm seen in Figure 3 was resected and grafted with a prothesis. Recovery was uneventful; peri- jiheral pidses remained.
Follow-up examination six months later confirmed an aneurysm in the other leg. Resection was done 8-5-65, and total occlu- sion of the popliteal artery distally was found. This was due to scarring of the in- tiina, seen at the distal end of the aneurysm in Figure 4. The collateral circulation was carefully preserved, the aneurysm resected, and the jnoximal end ligated. Extremity loss was exjrected but did not occur, cer- laiidy due to adequate collateral circula- tion. Presently, the patient has unilateral claudication only, with persistent pulses aiul no claudication on the grafted side.
Case 5. A 45-year-old musician suddenly developed a cold, waxy foot on 4-29-66. Four hours after onset, angiography, resection of a thrombosed popliteal aneurysm, and ])iosthetic grafting was done. The limb sur- vived, l)ut the patient was left with a per- manent lootdrop, preceded by the charac- teristic evolution of an ischemic anterior compaitment. No pulses returned. Two years later, the patient has a persistent foot- drop, but continues to play his vibraharp well.
Comment
Our small series of cases represents five |>atients with eight popliteal aneurysms. Of these, two were apparently patent and were operated upon electively; six were operated
34
Illinois Medical Journal
upon at the time of acute thrombosis, on emergency basis. Of these, three limbs sur- vived, but only one of these can be termed successfid in the sense of a non-sympto- matic limb with intact foot pulses. It ap- pears that our rate of success also is at 50% limb survival.
Since we work in a community hosjiital, dealing only sporadically with a wide va- riety of vascular problems, we find that we have had no continuing policy in dealing with popliteal aneurysms. We have dealt with each problem individually. There are certain factors which appear to have al- tered the clinical outcome of this disease. Some of these are matters over which the physician can exert no influence; some are matters in which the surgeon’s approach makes the difference between success and failure.
If the collateral circulation is adequate, the mode of treatment of thrombosed pop- liteal aneurysm makes no difference. Acute occlusion will be prognostically determin- alile if the usual signs of ischemia reverse tliemselves in a short while. Persistent sen- sory and motor loss almost always signify ultimate amputation. Recovery of motor activity and sensation usually signifies an ultimately useful limb. Limbs three and eight illustrate these factors. However, the extent of collateral circulation is a matter over which the physician exerts no in- fluence.
I’he physician does bear directly in other areas. Timing is of j^aramount importance. As in occlusive disease elsewhere, the longer a thrombus is extant, the further the prop- agation of clot into adjoining collateral vessels and in the distal run-off. The more
for July, 1970
I
prompt the excision of the thrombosed structure and re-establishment of arterial thrust, the more certain a surviving limb. Since most patients are under the care of those not oriented to these problems, stub born and persistent education and re-edu- cation remain fundamental to success. The time from thrombosis to grafting must not be more than 3 to 4 hours, if any success is to be obtained. Secondly, arteriography will definitely aid in differentiating acute arteriosclerosis obliterans from thrombosed popliteal aneurysm. The latter simply has to be approached from a stiaight posterioi position; unawareness of the differential re- sidts in a need for changing patient posi- tion or fighting a very poor exposure to the end of the operation. Limb loss always has medico-legal implications. Although the subtleties of occlusive disease may easily be interpreted by physical examination by the vascular surgeon, they are not so clear to other consultants, attorneys, and jurymen. An arteriogram permits easy explanation
Fig. 4
S5
and leaves a j^ermanent record for future reference.
Aggressiveness is certainly indicated in thrombosed jropliteal aneurysm. What to do with jratent popliteal aneurysms remains in doubt. Our limited experience with these was gratifying; I wish we had been so for- tunate with thrombosed aneurysms. If the patient can understand the problems in- volved and accept the risk of limb loss, ad- vising elective resection seems reasonable. In almost 30 years, no one has duplicated the results of Lintou, which were indeed excellent. The inescapable conclusion seems to be that lumbar sympathectomy contrib- utes considerably to limb survival when there develops a complication of popliteal aneurysm.
Concliision
The treatment of thrombosed pojrliteal aneurysnr is unsatisfactory. Earlier diag- nosis, arteriography, resection aird grafting seem the best solution. Lumbar sympathec-
tomy undoubtedly contributes considerably to recovery. Courage on the part of the surgeon and patient alike are necessary to permit excision and grafting of non-sympto- matic patent aneurysm. M
References
1. Linton, R. R.: “The arteriosclerotic popliteal aneurysm.” Surgery, 26:41, 1949.
2. Baird. R. J., Sivasankar, R., Hayward, R., Wil- son, D. R.: “Popliteal aneurysms: a review and analysis of 61 cases.” Surgery, 59:911, 1966.
3. Giftord, R. 4V., Hines, E. A., Jr., and Janes, J. M.: “An .Analysis and follow-up study of one hundred jtopliteal aneurysms.” Surgery, 33:284, 1953.
4. Friesen, G., Ivins, J. C., and Janes, J. M.: "Popliteal aneurysms.” Surgery, 51:90, 1962.
5. Crawford, E. S.. DeBakey, M. E., and Cooley, D. A.: "Surgical considerations of peripheral arterial aneurysms.” A.M.A. Archives of Sur- gery, 78:226, 1959.
6. Hunter, J. A., Jtilian, O. C., Javid. H., Dye, \V. S.: “Arteriosclerotic aneurysms of the pop- liteal artery.” J. Cardiov. Surg., 1:404, 1961.
7. Hara, M., Thompson, B. W.: “The hazards of popliteal aneurysms.” A.M.A. Archives of Sur- gery, 92:504, 1966.
Order reprints from 8ti0 Summit, Elgin, 60120.
Modern Diets Proving
Modem diets are proving harmful to the teeth of Eskimos living in northern Can- ada, a dental anthropologist at The Llni- versity of Chicago has reported.
A paper presented by Dr. John T. May- hall, a post-doctoral trainee at The Uni- versity of Chicago, describes preliminary studies which indicate that modern food now being consumed by Eskimos in the Northwest Territories of Canada is de- teriorating their teeth.
“A study of the teeth of the Eskimos of Igloolik and Hall Beach, Northwest Terri- tories, Canada,” Dr. Mayhall said, “reveals that with the introduction of modern foods and tastes, the dental health of the Eskimo inhabilants of these isolated Foxe Basin vil- lages is deteriorating.”
“The principal change affecting the den- tition during this modernization is a new diet which is extremely different from that which was prevalent only a short time ago and to which some of the Eskimos living in the more isolated circumstances still adhere.”
Dr. Mayhall said the tooth decay rate for permanent teeth in Igloolik nearly doid:)led in those people who had a diet consisting of more than 60% food obtained at the local stores as compared with those
Harmful To Teeth
individuals wlio.se diet is principally food olitained from hunting and fishing.
“ I'he latter’s main staples,” Dr. Mayhall said, “appear to be seal, cariboti, fish, and some walrus. Ccnerally, those who had the ‘native’ diet had less calculus (tartar) on their teeth than did those on the modern diet.”
The study was supported by the National Research Council of Canada through the Canadian International Biological Pro- gramme, Human Adaptability section. It was undertaken in 1968 to ascertain the effects of a rapidly changing culture upon the dentition of the Eskimos of the North- west Territories.
“It (the study) was a part of a multi- disciplinary study of Eskimos,” Dr. May- hall said, “and the results presented here are preliminary and based only upon the author’s (Dr. Alayhall’s) observations with- out the aid of results from the other in- vestigators. With this material available in the future, more enlightening data will be available.”
“At present, a comprehensive dietary sur- vey is under way by Miss Heather Milne of the Elniversity of Toronto, which will be available for a more detailed sttidy of the effects of diet.”
36
Illinois Medical Journal
4‘i |i^’'^#“
;;iv
V^'ty
"* <r-i-
■ ’ :?: f-*7-"'':4t5rtf '. /■'I'
»*=:■ •i''-^&'>-i*VY^'f
Surs;ical Grand Rounds are held weekly on Saturday at 8:00 a.m., alter- nating; between the Staff Room, Chicago Wesley Memorial Hospital, and Ofpetd Auditorium, Passavant Mejnorial Hospital. Patient presentations from these hospitals and from the Veterans Administration Research Hos- pital form the basis of the discussions. This case report was part of the Surgical Grand Rounds held at Passavant Memorial Hospital on March 22, "l969.
Ureteral
Obstrrictioii
Edited by John M. Beal, M.D.
CASE REPORT:
Dr. Gerald Halperii: A 76-year-old male was admitted to Passavant Memorial Hos- pital lor the first time on Feb. 26, 1969, (or the evaluation of recurring hematuria, riie patient was well until 1960, when, after an episode of hematuria, he was dis- covered to have a bladder tumor. Trans- urethral removal of the tumor was per- formed. l ire patient was well for five years. However, in 1965 he had an episode of gross hematuria and again transurethral resection of the bladder tumor was re- quired. From 1965 to 1968, the patient was subjected to cystoscopy yearly. On each oc- casion, a bladder tumor was found and re- sected endoscopically. In Jidy, 1968, an in- travenous urogram showed non-function of the right kidney. One month prior to ad- mission, he again developed total gross liematuria with dysuria and frequency and hourly nocturia associated with a dribbling stream and hesitancy.
Physical examination at the time of ad- mission: The patient was a pale, elderly white male. Blood pressure 160/70, pulse
Fig, 1. Intravenous pyelogram, four hours af- ter injection, demonstrated hydroncphrotic left renal pelvis.
38
Iltinois Medical Journal
Fig. 2. Triple exposure film of the bladder showed good mobility of the left bladder wall during emptying. The large arrow indicates area of fixation of right bladder wall.
72, temperature normal. Examination rvas within normal limits, except for the pros- tate which was moderately enlarged but smooth and symmetrical. Enlargement of the spleen, kidneys, or liver was not de- tected. Laboratory data shorved a hemo- globin of 7.1 Gm., hematocrit 22%. His white count was 6,400, and his sedimenta- tion rate was 69. BUN— 62, uric acid— 5.1, creatinine— 4.7 mg./%. Urine was sterile when cultured.
Dr. Michael Murphy: A double dose in- travenous pyelogram was done in Eebruary and it again showed non-visualization ol the right side. At 15-minutes there was faint visualization on the left. A follow-up him taken four hours after injection showed dehnite excretion of contrast material into a hydronephrotic left renal pelvis (Eig. 1). Renogram conhrmed the hndings of the LV.P. It showed poor function bilateralfy; there was uptake of radioactivity on the left, but none on the right. Cystogram failed to show intrinsic defects in the blad- der. After this study was completed, the bladder was distended with contrast ma- terial, and a triple exposure him was taken as the bladder emptied (Eig. 2). I believe you can see the three outlines of the blad- der wall on the left, corresponding to the
three exposures. However, the bladder wall on the right side is relatively hxed. Al- though hbrous adhesions from previous sur- gery and radiation could cause this, we thought that it was more probably caused by recurrent bladder tumor.
Dr. Halpern: At this time, the clinical im- pression was recurrent bladder tumor with bilateral ureteral obstruction causing urem- ia. After transfusions of whole blood, cys- toscopy was |rerformed on March 4. A bladder tumor could not be visualized en- doscopically: however, two suspicious areas at the bladder neck were biopsied, which did not demonstrate malignancy. He did have a stricture at the ureterovesical junc- tion and also a mild bladder neck contrac- tion. It was decided that the patient woidd benefit from diversion of his urinary stream, and therefore, two days following cysto- scopy, a left cutaneous ureterostomy was performed. The patient has had a satisfac- tory course since operation.
Dr. Joseph Sherrick: In spite of the fact that this patient had been treated for carci- noma ol the bladder since 1960, we were unable to find any tumor in the multiple biopsies of the bladder taken by Dr. Hal- pern. In one biopsy (Eig. 3), there was a
Fig. 3. Biopsy of bladder wall was interpreted as demonstrating edema and inflammation.
for July, J970
39
Fig. 4. The bladder mucosa was distorted and showed atypical hyperplasia, probably related to previous irradiation.
Structure composed of distended lympha- tics and edematous connective tissue which is an inflammatory polyp. The epithelium covering all the biopsies seemed thicker than in the normal urinary bladder. On close examination, one can see that there is some loss of stratification of the epithe- lium, but the transitional pattern is still preserved. Some of the epithelial cells are pleomorphic, but there is no mitotic ac- tivity (Fig. 4). We regard this as being atypical hyperplasia of the bladder epithe- lium and not cancer. This pecidiar dysplas- tic change may jrossibly be related to radia- tion or to unknown factors. It would be of great interest to have an opportunity to review the bladder biopsies taken from this patient at other hospitals since I960.
Dr. John Grayhack: This patient actually demonstrates the value of establishing a definite diagnosis. He presented with a his- tory which was typical for carcinoma of the bladder. He had had history of transitional cell carcinoma of the bladder with repeated recurrences documented over a nine year period. Hematuria and bladder symptoms were persistent. The patient then developed ureteral obstruction and was actually se-
verely azotemic and anemic when he was first seen by us. Our initial impression of this 76-year-old man was that he had both ureters obstructed by his carcinoma, one totally probably and the other partially for only eight months, and that there was little reason to be too vigorous in pursuit of either a diagnostic or a therapeutic regi- men. On reflection, we recognized that our presumptive diagnosis should be verified. Surprisingly, we could not document the presence of persistent malignancy despite multiple biopsies. We were unable to iden- tify either ureteral orifice at cystoscopic examination. These findings suggested that the patient had a fibrotic obstruction of both ureters following transurethral resec- tion, a phenomenon which is recognized but rare. Finder these circumstances, we elected to divert the patient’s urinary stream. Several types of permanent diver- sion are available in a patient who requires supravesical diversion (Fig. 5). Actually, nephrostomy tube drainage is a satisfactory form of diversion. It is usually used for temporary rather than long-term diver- sion. The various types of cutaneous ure- terostomy are also shown. Probably the most satisfactory is the high cutaneous ure- terostomy. This procedure utilizes the well vascidarized upper third of the ureter. Ureteral length is adequate to permit ure- teral cutaneous anastomosis without ten- sion. Fitting an adequate appliance to the ureterostomy site is difficult. The classical cutaneous ureterostomy, utilizing the mid- dle third of the ureter, produces a no- toriously bad result unless the ureter is di- lated. This is probably due to two factors: 1) the blood supply to this segment of ure- ter is poor. The lower third of the ureter receives the major portion of its blood sup- ply from below. In this procedure, you di- vide the ureter at about the site of its poor- est blood supply. 2) When you bring the ureter retroperitoneally, you rarely have enough length to reach the skin without tension. These factors result in a high inci- dence of stricture of the stoma and slough of the distal ureter, complications that have caused this particular type of diversion to fall into disrepute. The single stoma trans- peritoneal ureterostomy has been utilized primarily in youngsters but is gaining popu- larity in other instances since we have learned from the use of the ileoconduit that
40
Illinois Medical Journal
we can cross the peritoneal cavity with a tubular structure and still not get into too much trouble with intestinal obstruction. The classical and high ileal conduits are probably the most satisfactory types of su- pravesical diversion from the standpoint of long term survival. A mortality rate of about 3% is associated with the ileal con- duit for nonmalignant disease. Ureterosig- moidostomy, shown at the bottom of Fi- gure 5, cannot be utilized with safety in a patient who has a large, dilated ureter. It does have a place as a palliative proced- ure and actually has a place in some elder- ly patients in whom attempted curative sur- gery is carried out. It has a disadvantage in that there is a high incidence of pyelo- nephritis following it as well as the pecu- liar hyperchloremic acidosis which is asso- ciated with a large percentage of patients who have this type of diversion. In this man, we elected to do a cutaneous ureter- ostomy on the left side only since he was a poor risk patient. We knew that the right side was not functioning, at least by intravenous pyelography, for some ten months. The ureter which was obstructed at the ureterovesical junction was very thick-walled, a finding which suggests an increased blood supply to the ureter. This is the type of ureter which is ideal for a cutaneous ureterostomy. We brought the ureter in a transperitoneal course so that it could approach the skin directly and be under less tension. In the postoperative period, the patient had an interesting phenomenon which is often seen in pa- tients with marked renal failure. His blood urea nitrogen went from 60 to about 130 mg.%. His creatinine rose but not to the same extent as his BUN. The question of dialysing him was raised just about the time he began a diuresis. His BUN now is about 30. The phenomenon of apparent increas- ing renal failure in the postoperative period could well be related to an increasing ob- struction from the non-intubated cutaneous ureterostomy and the extra load placed on the kidney by the tissue breakdown associated with the surgical procedure. One thing that you must remember in a patient who has renal failure of this nature, who requires an operative pro- cedure, is that you have to be careful about fluid replacement and particularly about potassium administration or accumu- lation. Since hemolysis may increase the
Methods of Permanent Urinary Diversion
Cutaneous Ureterostomy
High Classical Midline Single Stoma
Ileal Conduit
Fig. 5. (labeled Methods of Permanent Urinary Diversion).
serum potassium of blood signihcantly, prior to administering large quantities of blood to these patients you ought to make an effort to get fresh blood and to arrange to monitor serum potassium and ECG changes closely.
Dr. John Beal: Was re-implantation of the ureter into the bladder considered?
Dr. Grayhack : This was a consideration. Despite the negative biopsies, we weren’t entirely sure that the patient didn’t have bladder cancer. We biopsied the lower end of the ureter and perivesical area; these biopsies showed fibrosis, but no evidence of carcinoma. This ureter had a diameter of about 1.5 cm., and probably two-thirds of that was the wall. To attempt to reimplant that in a man who already has renal failure and in whom any minor insult might be a terminal one would be very hazardous. If you knew the status of the bladder with certainty and if you had a ureter which you could implant, neither of which was true.
for July, 1970
41
reimplantation would deserve primary con- sideration. His right kidney is fnnctionless as far as we can tell. He passes no urine from his bladder. He undoubtedly has a hydronephrotic sac on the right side which we do not intend to molest.
Dr. Douglas Dahl: Were you certain that the right kidney was not making urine? Dr. Grayhack: No, I was not. We were faced with the possibility of doing a bi- lateral cutaneous ureterostomy for a non- functioning kidney which would leave us with an open infected draining stump and which would require prolongation of an operative procedure in a seriously ill old man. We considered doing a transuretero- ureterostomy, joining the right ureter to the left and bringing the left to the skin. We didn’t feel that it was worth while jeopardizing the one good ureter for one that we thought was no good. We felt that if urine production by the right kidney caused him symptoms without contributing significant function, and his left side re-
covered function, the ideal procedure would be to do a right nephrectomy in this man later. We were concerned about the status of the right kidney, but our assump- tions seem well founded.
Dr. Stuart Poticha: When you bring the ureter out to the skin of the abdomen, do you attempt to fix it to the lateral peri- toneal wall?
Dr. Grayhack: The transperitoneal ure- terostomy is not done commonly. We bring the left ureter medial to the colon, usually at the level of the sigmoid. A flap of pos- terior peritoneum with the mesosigmoid is utilized to cover the ureter in part. A major segment of the ureter is still retroperito- neal. We’ve not anchored the sigmoid to the ureter, although we’ve wondered about it. The ureteral blood supply is so tenuous, that we really hesitate to place sutures in the mid-ureter. We put one suture in the periureteral tissue as the ureter enters the parietal peritoneum and the posterior fas- cia; except for this, we rely upon skin su- tures to secure it.
New Pharmaceutical Specialties
{Continved from page 26)
Indications: Variety of infections susceptible to sulfonamide therapy.
Contraindications: Hypersensitivity to sulfona- mides. Infants less than 2 months of age. Preg- nancy at term and during nursing.
Dosaee: Varies with age and indication.
Supplied: Tablets, 0.5 gm.
STEPS Vasodilator P
Manufacturer: Dow
Nonproprietary Name: Pentaerythritol tetrani- t^ate
Indications: Relief and prophylactic treatment of angina pectoris.
Contraindications: Idiosyncrasy to drug.
Dosage: 1 capsule every 12 hrs. on an empty stomach.
Supplied: Timed disintegration capsules, 30, 50 and 80 mg.
tetanus immune
Gt.obuLIN (Human) Biological R
Manufacturer: Wyeth
Nonproprietarv Name: Human gamma globulin 16.5 (±1.5) % sol.
Indications: Immunization against tetanus Contraindications: Do not give intravenously. Dosage: Adults: i.m., 250 units.
Children: i.m., 4.0 units/kg.
Supp’ied: Solution (Tubex)
TUBERCULIN Diagnostic R
Manufacturer: Connaught Medical Research La- boratories, Canada Distributor: Panray Div., Ormont Nonproprietary Name: Stabilized tuberculin,
purifipd protein derivative (Mantoux) Indications: Intracutaneous tuberculin testing Contraindications: None mentioned.
Dosage: Initial intracutaneous tuberculin test, 5 T.U.
Supplied: Vials, 1-5 cc
COMBINATION PRODUCTS
FERROBID Hematinic R
Manufacturer: Meyer
Composition: Ferrous fumarate 225 mg.
Copper sulfate 8 mg.
Ascorbic acid 100 mg.
Indications: Prevention and treatment of iron deficiency anemias.
Contraindications: None mentioned.
Dosage: Adults: One capsule twice daily. More severe anemias: One capsule t.i.d.
Children: As directed.
Supplied: Duracap timed action capsules.
DEMULEN Oral Contraceptive R
Manufacturer: Searle
Composition: Ethynodiol diacetate 1 mg.
Ethinyl estradiol 50 meg.
Indications: Oral contraception.
Contraindications: Thrombophlebitis, thrombo-
embolic disorders, cerebral apoplexy or a past history of these conditions. Markedly impaired liver function. Known or suspected carcinoma of the breast or estrogen-dependent neoplasia. Undiagnosed abnormal genital bleeding.
Dosao'e: One tablet daily in 20 day cycles.
Supplied: Tablets.
MTC Oil Nutrient o-t-c
Manufacturer: Mead Johnson
Composition: Lipid fraction of coconut oil con- sisting primarilv of triglycerides of the C^, and C,r, saturated fatty acids.
Indications: Restriction of dietary fat intake to medium chain triglycerides.
Contraindications: None mentioned.
Dosage: 3-4 tbs. daily mixed with food.
Supplied: Oil
42
Illinois Medical Journal
1
Do It! By Jerry Rubin, Simon and Schus- ter, New York, N.Y. $2.45
In the wake of the violence that swept across the campuses and the country in the past few weeks, we have become intrigued with a depraved little volume published by Simon and Schuster called Do It! Written by Jerry Rubin, one of the “Chicago 7” gang recently convicted of crossing state lines to provoke a riot, the book— aside from being saturated with obscene language —spells out some of the thinking of Ameri- ca’s youthful revolutionaries.
Rubin, indeed, is quite frank. He says the idols of the New Left are Che Guevara, Fidel Castro, and the Viet Cong— and he appears to relish the idea of bringing guer- rilla warfare to the United States.
He approves of virtually any tactic to bring clown the Establishment, including sabotage, treason and the killing of cops. “We’ve combined youth, music, sex, drugs and rebellion with treason— and that’s a combination hard to beat,’’ he says at one point.
At still another: “When in doubt, burn. Fire is the revolutionary’s god. Burn the flag. Burn churches. Burn, burn, bnrn.” Jerry is also for stealing: “All money is theft,’’ he says. “To steal from the rich,”
he continues, “is a sacred and religious act. To take what you need is an act of self- love, self liberation. While looting, a man to his own self is true.”
The well-known Yippie leader acknowl- edges that the demands of demonstrators are deliberately unreasonable. The basic bargaining tactic of the revolutionary, he says, is: “Give us an inch— and we’ll take a mile. Satisfy our demands and we got 12 more. The more demands you satisfy, the more we got. . . . Demonstrators are never reasonable. We always put our demands forward in such an obnoxious manner that the power structure can never satisfy us and remain the power structure. Then, we scream, righteously angry, when our de- mands are not met.”
Jerry Rubin has written The Communist Manifesto of our era. Do It! is a Declara- tion of War between the generations— call- ing on kids to leave their homes, burn down their schools and create a new so- ciety upon the ashes of the old. . . .
For those of you who appreciate the form of government we now have, you might want to read about those who would change our system. You may not enjoy reading Do It! but it should be an eye opener.
The Pill
Science writers also appear to be moving toward more sophisticated levels of analytical reporting of science's economics, politics and priorities. In his book, THE PILL, Morton Mintz of the Washington Post chronicles just how the degree of danger seen in birth control pills depends a great deal on the expert's viewpoints. Medical scientists fixed upon the problems of population explosion rate the risks as very small, less dangerous than preg- nancy. Researchers and doctors focused on individual patients, generally in the upper and middle classes, considered the risks of pregnancy less serious than risking complications associated with hormone contraception. Judith Randal, writing in the Washington Star, criticizes the medical men for for- getting—or ignoring— the desirability of warning patients that all powerful drugs involve risks. (Warren Burkett, "There's More Going On in Science Than Some Would Tell," The Quill [May] 1970, pages 16-19.)
r
for July, 1970
43
Failure of thymectomy
In a six-year old child
With myasthenia gravis
By Chang Hwan Kim, M.D., Bennett R. Sherman, M.D., AND Meyer A. Perlstein, M.D. /Chicago
Thymectomy for myasthenia giavis was first reported in 1939, by Blalockd Most re- ports deal with thymectomy in adults; only a few in children.
d’hymectomy has been jrerformed mainly when a thymoma is present and particular- ly in female patients between 20 and 35 years of age. Since, with advanced surgical technics, thymectomy can be carried out with minimum risk, the procedure may be indicated when there is poor response to medical regimen.
The case being reported here documents another instance of myasthenia giavis in a 6-year old child and the failure of thymec- tomy to have therapeutic benefit.
Case Report
H. C., an 18-month-old Negro male (6 years old at the time of surgery) was admit- ted to the Children’s Division of Cook County Hospital on Nov. 11, 1962, for evaluation of complaint that for two weeks he was unable to open his right eye. The patient appeared normal in the morning, but later in the day his right lid began to droop, and by evening was almost com- pletely closed. He was first born to a 20- year old mother after an uncomplicated pregnancy. Birthweight was eight pounds. There was no history of familial or heredi- tary illnesses.
On physical examination, ptosis of the right lid was the only abnormal finding. At a previous admission for respiratory in- fection two months earlier, no eye abnor- mality had been noted. There was no dys-
phagia. Five milligrams of Tensilon was injected intravenously following which the child was able to move his lid in normal fashion. A diagnosis of myasthenia giavis was made.
Treatment was begun with prostigmin, 7.5 mg. giadually increased to 22.5 mg. t.i.d., and ephedrine, 8 mg. each morning.
Chang Mwan Kim, M.D. (far left), is a pedi- atric neurolo- gy consultant, Reed- Chicago State Hospital. He is a graduate of the Yeun Sei Univ. College of Medicine, Seoul, Korea and served his internship in Al- bany, N.Y., and a residency at Jefferson Medical College Hospital, Philadelphia. In ad- dition he has done fellowship work in pediatric neurology under the United Cere- bral Palsy Foundation at Cook County Hospital. Ben- net R. Sherman, M.D., (left) is a practicing pediatrician and an associate in pediatrics at Cook County, Evanston Hospi- tal and Northwestern Univ. Medical School. He received his M.D. from the Univ. of Illinois College of Medicine and served his internship and residency at Michael Reese. M. A. Perlstein, M.D. (below left) was professor of pediatrics, Northwestern Medical School and head of Pe- diatric Neurology at Cook County Hospital. A graduate of Rush Medical School, Dr. Perlstein served his internship and residency at Cook County. Dr. Perlstein died recently after mov- ing to California.
44
Illinois Medical Jourrml
The ptosis however, did not improve. In fact, the patient developed ptosis of the left lid also. Prostigmin was discontinued and the patient was started on Mestinon, 120 mg. daily, gradually increasing to 60 mg. q.i.d., before a favorable response was obtained. The child was discharged on Dec. 22, 1962, six weeks after admission.
Continuing Treatment
Following this hrst admission there have been 13 additional admissions to the hos- pital in five years. Many of these were for respiratory distress, with asthma generally associated with a bronchiolitis which re- sponded to epinephrine, aminojahylline and intravenous fluids.
On admission on January 20, 1966, he was also given corticosteroids. At this time, a cholinergic reaction was considered and Mestinon was withdrawn. Ptosis and asth- matic symptoms persisted. The patient be- came refractory to Mestinon and the ptosis persisted in spite of giving sufficient drug to cause abdominal cramps. The patient was then tried on Mytelase, 5 mg. t.i.d. increasing to 10 mg., t.i.d. This also was discontinued after a week when the patient failed to respond.
An electromyogram was normal. I’he pa- tient was discharged without medication and was doing well other than for ptosis until he was re admitted on Dec. 1, 1967, at the age of 6 years, in acute respiratory distress with asthmatic symptoms. His acute symptoms were alleviated with epinephrine, aminophylline, Tedral and supportive mea- sures. Examination at this time showed total paralysis of all extra-ocular muscles.
Laboratory work including hemogram, urinalysis and blood chemistry was normal. Chest X-ray showed no thymic enlarge- ment. Because of his extreme refractiveness to medical treatment, thymectomy was done on Dec. 15, 1967. The thymus was enlarged with extension of its lateral lobes up into the neck. It weighed 35 grams ujion re- moval (normal for this age is 24 grams). Histologically the specimen was normal. His post-operative course was uneventful. There was no immediate or late post-opera- tive improvement in his ptosis or ocular muscle palsy.
The patient was followed in out-pa- tient clinic for six months. There was no improvement. Mestinon now caused cholin-
ergic reactions in previously tolerated doses, in spite of the use of atropine sulfate. No drugs are being given at the present time and the patient remains as before surgery- no better, no worse. There is still a bilateral ptosis and ophthalmoplegia.
Discussion
Myasthenia gravis is rare in infants and children. The disease seems more prevalent in Negroes in our own and in Dr. Ford’s clinic and in the age range of 18 months to 10 years.^
The incidence in females is 4.5 times higher than males during the hrst decade.^^ Those reported in the neonatal period are usually a transient illness passively trans- ferred from an affected mother.^^’-"* The prognosis in children is generally poor de- spite the use of a large variety of pharma- cologic agents as well as X-rays and thy- mectomy. Although muscle weakness and dysphagia are frequently benehtted by drug therapy, ptosis and ophthalmoplegia are the most refractory symptoms. The period of adolescence is a most difficult barrier.
Thymectomy has been done with thera- peutic beneht mainly in adults with myas- thenia gravis whose response to medical regimen had been unsatisfactory.
In 1950, Ritter and Epstein^i reported a 9-year-old child who died about 4 months after thymectomy without any post-opera- tive beneht. Thymectomy was of no avail in the case of a 14-year-old girl, reported by Goya.® The youngest patient with myas- thenia gravis in whom thymectomy had a favorable effect was a 25-month-old girl re- ported by Sutin and Hewiston.-®
The most encouraging report of beneht from thymectomy in children with myasthe- nia gravis is that of Keynes^^ who cured 14 of 21 children (21/9 to 16 years) so that they no longer needed drugs. In reviewing the study of 78 patients subjected to thymec- tomy in the report of Schwab and Leland,-- more beneht from surgery was obtained in female than male patients and in those 21 to 30 years of age. The remission rate af- ter 31 years of age was very low, particular- ly in males.
Osserman and Genkins-® hold that age rather than sex is the major factor in the selection of patients for thymectomy; rela- tively young patients with recent onset of symptoms do best. Simpson’s“^ study, on
for July, 1970
<5
the other hand, showed little evidence that better operative residts are obtained in the younger and female group.
The child presented in this report had ocular myasthenia which started with ptosis of the right lid and progressed to involve the left lid and then all of his extraocular muscles. The incidence of ocular myasthen- ia varies from 4.5% to 29.7%.“^
Altliough patients with myasthenia gravis are usually referred for surgery when thy- moma is present regardless of the severity of the disease, " " the result was poor
in the reports of Keynes, Schwab and Leland-- and Simpson.-® In the report of Kreel, Osscrman, Genkins and Kark,!® the patients with thymic hyperplasia were more benefitted than the patients with thymoma.
The indications for thymectomy in my- asthenia gravis given by Kreel, et ab® were: I) Thymoma, all patients: 2) Benign hyper- plasia, under 40 years with onset less than five years previously and relractory to medi- cation. According to Kreel, et al,^® 14 or 15 thymectomized patients had a dramatic, though sometimes transitory, remission of their myasthenic symptoms immediately af- ter recovery from anesthesia. Our patient had no such remission.
The concomitant presence of bronchial asthma, non-cholinergic, with recurrent acute attacks in our case may be an import- ant part in the refractory resjjonse to medi- cal and surgical treatment. In the report of Kreel ct al, the only mortality among the 15 patients operated was an 18-year-old girl with myasthenia and bronchial asthma.
In adidts, the younger the ])atient, the shorter the history, the better the response to thymectomy.®'® '® However, to assess the effect of thymectomy as a treatment of my- asthenia gravis in infants and children, there should be a critical review of a large number of cases. The rarity of this disease in children puts this task far ahead.
Summary
A case of myasthenia gravis in a 6-year- old child is reported with an unsatisfactory response to medical and surgical treatment. Two elements are considered as the possible contributing cause of failure to respond to thymectomy in spite of having had a large thymus:
1. Concomitant presence of non- cholinergic bronchial asthma:
2. Presence of ocular myasthenia. ◄
References
1. Blalock, A., Mason, M. F., Morgan, H. J., and Riven, S. S.; “Myasthenia gravis and tumors of thymic region: Report of a case in which tumor was removed.” A/in. Surg., 110:544, 1939.
2. Bowman, J. R.: “Myasthenia gravis in young children.” Pediatrics, 1:472, 1948.
3. Eaton. L. M., and Clagett, O. T.: “Recent sta- tus of thymectomy in the treatment of myas- thenia gravis.” Amer. J. Med., 19:703, 1955.
4. Ford, F. R.: Diseases of the Nervous System in Infancy, Childhood and Adolescence, ed. 5. Springfield, 111.: Charles C. Thomas, p. 1261, 1966.
5. Gerstle, M. Jr.: “Myasthenia gravis: Remarks on tlie age incidence: Report of a case.” Calif, and West. Med., 30:113, 1929.
6. Goya, N. H., Matshumoto, T. M., Tshboi, C. Z., and Seumiyoshi, A. N.: “A case of myasthenia gravis without the validity of thymectomy.” .Saishin Igaku. 21:1823, 1966.
7. Hatcher, C. R., Exarhos, N., Logan, W. D., and .Vbhott, O. A.: “Thymectomy for tumor and myasthenia gravis.” Dis. Chest, 52:350, 1967.
8. Henson. R. Stern, G. M., and Thompson, V. C.: “Thymectomy for myasthenia gravis.” Brain, 88:11, 1965.
9. Kawaichi, G. K. and Ito, P. K.: “Myasthenia gravis: Report of its occurrence in a 21 -month- old-infant." Amer. J. Dis. Child., 63:354, 1942.
10. Kennedy, F. S., and Moersch, F. P.: “Myas- thenia gravis: A clinical review of 87 cases ob- served between 1915 & early part of 1932.” Can. Med. Ass. J., 37:216, 1937.
11. Keynes, G.: “Investigations into thymic dis- eases & tumor formation." Brit. J. Surg., 42:450, 1955.
12. Keynes, G. “Surgery of thymus gland.” Lancet, 1:1197, 1954.
13. Keynes, G.: “The surgery of thymus gland.” Brit. J. Surg.. 33:201, 1946.
14. Keynes, G.: “Surgical treatment of myasthenia gravis. " Lancet. 1:739, 1946.
15. Kreel. I., Genkins. G., Osserman, K. E., Jacob- son, E., X: Baronofsky, I. D.: “Studies in myas- thenia gravis.” Arch. Surg., 81:251. 1960.
16. Kreel, I., Osserman, K. E., Genkins, G., & Kark,
E.: “Role of thymectomy in the manage- ment of myasthenia gravis.” Ann. Surg., 165:- 111, 1967.
17. Lahranche. H. G., & Jefferson, R. N.: “Cong, myasthenia gravis.” Ped., 4:16, 1949.
18. Levethan, S. T., Eried, J., & Madonicke, M. J.: "Myasthenia gravis: Report of a case in which prostigmin methylsulfate was used.” Amer. J. Dis. Child., 61:770, 1941.
19. Lieberman, .\. T.: “Myasthenia gravis with acute fulminating onset in a child 5 years old.” J.A.M.A., 120:1209, 1942.
20. Osserman. K. E. X: Genkins, G.: “Studies in myasthenia gravis.” New York J. Med., 61:2076, 1961.
21. Ritter. J. .A.., X: Epstein, N.: “Some observa- tions on the effect of various therapeutic agents, including thymectomy X: .ACTH in a 9 year old child.” Amer. J. Med. Sci., 220:66, 1950.
22. Schwab, R. S. X: Leland, C. C.: “Sex X: age in myasthenia gravis as critical factors in inci- dence X: remissions.” J.A.M.A.. 153:1270, 1953.
23. Simpson. J. “.An evaluation of thymectomy in myasthenia gravis.” Brain, 81:112, 1958.
24. Strickroot. F. L., Schaeffer, R. L., X: Bergo, H. I..: “Myasthenia gravis occurring in an in- fant born of a myasthenic mother.” J.A.M.A., 120:1207. 1942.
25. Sutin, G. J., & Hewiston, R. P.: “Myasthenia gravis in a 2 year old child treated by thymec- tomy.” S. Afr. Med. J., 40:1002, 1966.
26. A'ahr, M. D. X: Davis, T. K.: “Myasthenia gravis: Its occurrence in a 7 year old female child.” /. Pediat., 25:218, 1944.
46
Illinois Medical Journal
Medical Progress
Harvey Kravitz, M.D. Medical Progress Editor
Conte raporary Practices
in
Opiitiialmology
“Our sight is the most perfect and most delightful of all our senses. It fills the mind ivith the largest variety of ideas, converses until its ob]ects at the greatest distance, and continues the longest in action without being tired or satiated with its proper enjoyments.”
—Joseph Addison (The Spectator) 1812
By John G. Bellows,
Sight is man’s most jarecious and usefid means of sense perception; yet it is a cruel irony that thousands of Americans need- lessly become blind every year. Sight en- ables man to probe all dimensions and dis- tances, whereas the other senses that en- hance the human personality are effective only through actual contact or close prox- imity.
Vision, in its narrowest and broadest sense, permits man to explore both the near world and to reach into the distant corners of the universe. Almost 85%
John G. Bellows, M.D., Ph.D., is an ophthalmologist, associate professor of Oph- thalmology at Northwestern University Medical School. He is on staff at several Chicago hospitals. He received his M.D. from the University of Illinois, and an M.S and Ph.D. from Northwestern Univer- sity. He took his internship and residency at Cook County Hospital and is the author of two hooks in his field as well as more than 80 papers. Dr. Bellows is a founder of the Society of Cryosurgery and is editor of Annals of Ophthalmology.
M.D., Ph.D. /Chicago
of our knowledge of the outside world is gained through visual perception. Man uti- lizes this visually acquired information to ascertain facts, to form opinions, and to make judgments.
The knowledge explosion that continues apace in all of medicine is perhaps nowhere more evident and dramatic than in oph- thalmology. Even the ophthalmologist with an extensive practice is hard-pressed to keep abreast of the continuing advances in this dynamic held. It must be conceded that the physician has a tridy difficult problem because he is concerned with keeping cur- rent in many helds. However, some knowl- edge of the latest work in ophthalmology will be most valuable because the physi- cian is frequently the hrst to be consulted and many eye conditions recjuire early and vigorous treatment.*
O
The well informed physician should be able to administer proper treatment, coun- sel and advice for some ocular problems
*Writi?2g in the June, 1970 Annals of Ophthalmol- ogy, Dr. Morris Fishhein cites a pertinent observa- tion by Dr. Francis Head Adler: "Of all the spe- cialties, ophthalmology is nearest to general prac- tice.’’
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and diseases and to recognize his limitations in managing other eye diseases requiring specialist care. Although it would be im- possible to describe in one paper all of the important ophthalmologic advances of re- cent years, the information that is of par- ticular significance and interest to the in- ternist and general physician will be de- scribed.
How We See
No longer tenable is the old belief that sight is the result of an object forming an image on the retina which is transmitted to the visual cortex of the brain to produce a “picture.” The role of the brain in the visual process is now known to be far more complex and to be more closely analagous to data processing than to the formation of an actual image. ^
The visual image of an object per se goes no further than the retina. The visual cortex of the brain receives nerve impulses first generated in the retina; these are de- coded in the brain. The pathway for the visual impulses which begin in the photo- receptors of the retina is along the optic nerve. At the chiasma the optic nerve sep- arates into two halves, with the nasal halves crossing over. Thus the fibers, from the lateral half of one eye and the nasal half of the other eye, unite to form the optic tract which is the pathway that leads the stimuli to the lateral geniculate body. Here the receptive ganglion cells receive the im- pulses from the homologous halves of the retinas. At this junction, chemical sub- stances are released producing impulses which are transmitted by means of the optic radiations to the visual cortex of the brain. These impulses travel at the rate of about 100 meters per second. The visual cells of the brain which are in the calcarine fissure of the cerebral cortex receive these impulses and immediately proceed with decoding the stimuli. In a method resembling data proc- essing the visual cells yield “bits” of data which are conceptualized by the individual in the form of the image he sees.
Not only visual information arises from the activity of the stimulated cerebral visual cells but also responses to suit the occasion are generated. In lower animals the most important responses center around survival, and the reactions are instinctive. Sight plays a larger role in man than in animals be- cause man has developed binocular vision
with depth perception. These capabilities enable man to judge distance. “Man sees a landscape, but the lion smells it,” is an old adage. Conversely man’s ability to smell and to pinpoint the source of an odor is far inferior to that of many animals. The superiority of man over lower animals de- pends in a large measure on his ability to see better and also to build up experiences. As a result of his siqrerior sight, man en- joys the greater powers of recognition, mem- ory, habit, logic, evaluation, and judgment. The stereoscopic qualities of his vision and the ability to converge, enabling man to develop manual and other skills, have re- sulted in the growth of his brain and his power to think.
Bacterial Infections of the Eye
Lhitil about 1945, infections of the eye by Neisseria gonorrhoeae, Corynebacteria diphtheriae and Diplococcus pneumoniae were common causes of blindness. Since that time loss of vision from these organisms has been virtually eliminated.
Now the staphylococcus group of organ- isms, especially those which produce peni- cillinase and those which develop resistance to the common antimicrobial agents, are of growing concern to the ophthalmologists. Drug resistance plays a greater role in the infections caused by staphlococci than in those caused by any other organism.
Resistant staphylococci are frequent in- habitants in hospitals, especially among patients, attendants, nurses, residents, and the attending staffs of physicians. The re- sistant patterns vary from hospital to hos- pital depending upon the most common antibacterial agents used in the particular institution. The patient may actually be infected in the hospital; this has been demonstrated in patients whose conjunctiva were free of pathogenic organisms on en- tering the hospital but whose cultures two or three days later showed them to be har- boring staphylococci in their conjunctivas. It is conceivable that if these patients un- dergo intraocular suigery the ubiquitous staphylococci may invade the wound and cause an intraocular infection.
In many instances it is impossible to iden- tify the infectious agent causing the intra- ocular infection. When infection occurs, the eye surgeon employs an antimicrobial agent that is not commonly used at the
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Illinois Medical Journal
hospital. He chooses an antibiotic that has a broad spectral base to attack gram nega- tive organisms that may also be present. For these reasons, eye surgeons presently substitute for penicillin one of the follow- ing agents: methicillin, erythromycin, colis- tin, gentamycin, sodium cephalothin and cephaloridine.
External Viral Infections of the Eye
In this country the most common exo- genous viral infections of the eye are her- pesvirus keratitis and infections caused by the adenovirus types 3, 7, and 8. The ade- novirus infections of the eye are self-limit- ing and cause no visual impairment.
Herpesvirus infection has been known medically for centuries. The word herpes is of Greek origin meaning “creep.” Neat ly 100% of the population harbor the virus. The tendency for latency and repetitive eruptions are well known to the physicians. When herpesvirus infection involves the cornea (herpesvirus keratitis) it may cause serious impairment of sight. This viral in- fection of the cornea is now the leading cause of corneal scarring, having replaced trauma and bacterial infections that were formerly the chief causes of impaired vision from corneal scarring. An acute herpetic eruption of the cornea may be precipitated by exposure to sunlight, wind, or the appli- cation of eye drops containing steroids. The high fevers accompanying malaria may also precipitate a herpesvirus eruption. This type of infection is of importance to the military ophthalmologist in Vietnam as well as to civilian physicians treating ma- larial infected American veterans who may have recurrent high fevers. The tendency of herpesvirus keratitis to recur and to be- come chronic frequently leads to the in- volvement of the corneal stroma with per- manent corneal scarrinsr.
O
Fortunately, in recent years the use of IDU (5-iodo-2’ deoxyuridine) and the new- er antiviral agents have been a major con- tribution in combating herpesvirus kera- titis. Another new advance in the treatment of this disease is the application of low temperature by means of a cryoprobe ap- plied to the herpes lesion of the cornea. Re- covery rates following cryotherapy have been reported to be over 95%, in contrast to the 50-70% recovery rate with antiviral agents. 2 Even more recently, the use of in-
terferon inducers offer great hope for pre- venting visual loss from this disease.
Transfer of Maternal Viral Infections to the Fetus
Viral infections with ocular involvement can be transferred from the mother to the embryo or fetus and result in very serious problems. Rubella, rubeola, and cytomega- lic inclusion diseases are of greatest im- portance in this regard.
An infection of the embryo in its early days of development will cause more serious malformations and even a miscarriage. It follows that infections later in pregnancy, when most of the organs have already been formed, will produce less serious effects. A miscarriage or a stillbirth may occur even when the mother has fully recovered. Oc- casionally the mother may have a very slight infection which appears insignificant, or she may not even be aware that she has had an infection, but at birth the fetus may show serious eye malformations as well as marked defects of the heart and other parts of the body.
Early recognition of the infection in the mother enables the physician to alert the parents to the possibility of fetal malfor- mations and even its death. Some physi- cians employ gamma globulin although its value is questionable. The real hope for the elimination of the rubella virus as a factor in producing ocular defects lies in immunization programs with vaccines.
PLT Group of Atypical Viruses
In the Ehiited States eye infections by the psittacosis-lymphogranuloma-trachoma group of atypical viruses have become rare. However, the PLT group is still a major cause of blindness in underdeveloped countries. Even in these regions, trachoma, the most important disease of the group, could be eliminated if those governments made concerted efforts to treat patients with local and systemic sulfonamides, tetra- cyclines, streptomycin, rifampin and other antibiotic agents.
Glaucoma
It is estimated that two million persons in the United States over the age of 35 are threatened with incurable blindness from glaucoma. If untreated, glaucoma destroys the optic nerve. More than half
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49
ol the potential glaucoma patients are un- aware of the presence of the disease. In most instances there is autosomal dominant inheritance.
It is advisable that physicians test the intraocidar jrressure when performing rou- tine physical examinations on adults. The test and equipment merely call for a sur- face anesthetic and an inexpensive tonom- eter. Ophthalmologists or eye residents will gladly demonstrate this simple test to a phy- sician upon request.
I'he most common forms of this disease in adults are simple or open-angle glau- coma and acute or narrow-angle glaucoma. Narrow-angle glaucoma usually requires surgery, and this shoidd be performed early in the course of the disease before ocular damage occurs. On the other hand, open- angle glaucoma is readily controlled by medication.
Pilocarpine is the chief drug employed in the treatment of glaucoma and was the first direct-acting cholinergic compound to be used in glaucoma therapy. A one per- cent solution of this agent will frecpiently constrict the pupil lor a jreriod of five to six hours. If pilocarpine fails to control the intraocular tension the ophthalmologist will prescribe either the short-lasting phy- sostigmine or the long lasting carbachol, isoflurophat, echothiophate, and demecar- ium bromine.
If the administration of miotics and epinejrhrine does not control the ojten- angle glaucoma, the surgeon will then at- tempt to reduce the rate of aqueous for- mation. In mild types of this disease the carbonic anhydrase inhibitors (acetazola- mide, methazolamide, dichlophenamide and ethoxy/olamide) will aid in controlling the intraocular pressure. If these agents are in- elfective the surgeon may employ cryocy- clotherajjy. This painless procedure (cryo- cyclotherapy) may even be jrerformed as an olfice procedure ret|uiriug only a few drojis of a sm lace anesthetic. The techni()ue is simide. The ophthalmologist places the tip of the cold applicator (at about — 100°C) to the region of the ciliary processes and ciliary body (4 to 5mm from the limbus of the cornea). Freezing at very low tempera- tures causes atrophy of the ciliary body and ciliary processes and thereby reduces the amount of aqueous formation. This cryo- surgical procedure is particularly effective in elderly patients in whom the ciliary body
and processes are already partially atro- phied.
The Crystalline Lens
One of the major causes of impaired vi- sion in adults over 65 years of age is cata- ract. In recent years a great amount of in- formation has been developed on the bio- chemistry of the clear and cloudy crystal- line lens. In addition, the electron micro- scope has been of great value in estab- lishing the architecture of the lens.
The lens is an excellent osmometer. Wdren excessive glucose, drugs or toxins reach the aqueous humor its osmotic pres- sure is increased. This withdraws water from the lens. When normal osmotic levels are restored, the increased concentration of the aforementioned substances attracts water to enter the lens. These osmotic changes in the lens: dehydration, hydra- tion, and return to normal are accompan- ied by corresponding transitory refractive changes: myopia, hyperopia, and restora- tion of the normal refractive state.
The lens which originates from the sur- face ectoderm differs from the skin in that the oldest cell hbers are in the center and the youngest cell hbers are most superhcial. Since lens hbers remain within the lens cap- sule throughout the life of the individual any traumas in the broadest sense, i.e., meta- bolic disturbances, toxins and radiation, leave a permanent mark. These changes make the lens an excellent sensitometer and chronometer. The mark in the form of an opacity corresponds to the time in life when the injury occurred. From this, the exjterienced ophthalmologist is able to estimate the approximate date of the opac- ity with the biomicroscope. The technique of dating the opacity in the lens is termed phakochronology (Gk. phakos = lens— chronos time). This technique is of spe- cial inqrortance in settling medicolegal dis- putes.
Cataract Surgery
In recent years many dramatic improve- ments have made cataract surgery simple aud sale so that jratients no longer need to lear this type of surgery.
Eliminating the technical details of sur- gery, the most important improvements have been 1) cryoextraction which permits the surgeon to obtain a superior grasp on
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Illinois Medical Journal
the lens, practically eliminating capsular ruptnre and permitting removal of the lens throngh a smaller incision; 2) physical or enzymatic zonulolysis to free the lens from its attachments; the latest development in this area has been hydrokinetic zonulolysis in which the surgeon uses sterile balanced salt solution to rupture the zonules; 3) im- proved needles and suturing materials, al- lowing the stirgeon to close the wound and to make the anterior chamber air-and- water-tight; this permits early ambnlation; 4) neuroleptanalgesia prodticed by the newer drugs places the patient in a state of basal anesthesia; this permits the surgeon to operate on a trancpnl and cooperative patient.
I’hus cataract snrgery has become so re- fined and safe that even the very infirm and elderly patient may have his sight restored once again to see the faces of his family and friends and to resume the normal ac- tivities within his physical capabilities.
Retinal Detachment
Retinal detachment is the separation of the retina from the underlying pigment layer resnlting from a tear or a hole in the retina. These holes or tears usually re- sult from degenerative or myopic thinning of the retina. Fluid enters through the retinal hole, raising the retina and pro- ducing loss of vision.
Surgery is the only effective treatment, yielding successfid repairs in 80-90%. Un- fortunately, the surgical result is not al- ways accompanied by a restoration of the visual acuity to its former state, especially if the macula area has been involved. The good surgical results are attributable to Itetter materials and implants and im- proved technical procedures inchiding the application of low temperature instead of diathermy to produce adhesive chorioreti- nitis to seal the holes.
Ocular Complications of Diabetes Mellitiis
Better medical management of diabetes extending the life span of the diabetic has led to an increase in the incidence of ocu- lar complications. The two major ocular complications are diabetic retinopathy and cataract.
lire incidence of diabetic retinopathy increases with the duration of the disease.
Thus, if the onset of the diabetes occurs in a young individual, retinal changes will likely develop within a period of 16 to 18 years. Similar changes occur in the vessels of the kidney and other organs. All forms of treatment are relatively ineffective, in- cluding ablation of the hypophysis, the nse of lipotropic agents, vitamin therapy, and ratlical changes in the diet. Some ophthal- mologists report that sealing the areas of retinal leakage by photo-coagulation re- duces the edema of the macula and im- proves the visual actiity. Other ophthal- mologists doubt the value of photocoagtda- tion. Recently Fabrykant and his co-workers reported that a high-protcin-low-fat diet together with carbazochrome (.Vdrenosem Silicylate)* and anabolic steroids will catise an improvement in the retina and in the visual acinty.'^
Diabetic cataract is seen only in juvenile diabetics. In older individtials the cataracts that form are indistinguishable Iroin the ordinary senile cataracts. The treatment of cataract is surgical removal. The results in diabetics depend upon the condition of the blood vessels of the iris and retina. In the absence of retinal involvement and rue- bosis irides, cataract surgery in diabetics offers no special problems.
Vascular Diseases of the Retina
Pathological changes in the retinal vas- cnlature occtir not only in diabetes mellitus but are also common in hypertension and arteriolosclerosis. The importance of exam- ining the ftindtis of the eye is that hyper- tensive and arteriolsclerotic changes ob- served in the retina are paralleled by simi- lar alterations in the renal vessels. Thns the physician obtains valnable information as to the state of the vessels in the kidney by ophthalmoscopic examinations.
There are four stages of hyjjertensive vascidar disease: In the early stage, hyper- tensive arteriolo-retinal vessels are some- what narrower than normal; they will ap- pear “coppery.” In stage II the attennation of the arteriolar vessels becomes more pro- nounced. Focal areas of marked constric- tions indicate local vascular spasms. In stage III, edema and flame-shaped hemor- rhages make their appearance. Finally, stage IV shows the additional feature of edema of the optic disc.
*SEMED Pharmaceuticals.
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In a recent report, Wendland states that the degree of hypertension is more import- ant than age as a factor in the production of arteriolosclerosis. Diabetes mellitns, if present, accelerates the rate of progression of arteriolosclerosisd
Venous obstruction. Obstruction of the central retinal vein may come on with dra- matic suddenness with almost complete blindness. The ophthalmoscopic findings are so distinctive that, when associated with sudden loss of vision, they make the diag- nosis unmistakable. The physician viewing the fundus with an ophthalmoscope will observe the marked dilation of the veins accompanied by “brush-stroke” hemor- rhages in the retina. If only a tributary vessel is involved the above findings are localized in that area.
Until recent years, treatment was limited to the use of anticoagulants and the occa- sional use of hbrinolytic enzymes with gen- erally poor results. Recently an important advance in therapy was reported when Rad- not demonstrated that the intravenous ad- ministration of dextran produced a striking rate of recovery.'’’ This was especially true if treatment was begun early. It is now rec- ognized that a great many strokes are ac- tually the result of carotid occlusion. Among the early warning symptoms of im- pending closure of the carotid artery are signs of transient ipsilateral loss of vision and even homonymous hemianopsia. These ocidar symptoms may be accompanied by transitory hemiplegia. When these signs are present it is imperative that ophthalmody- namometry be employed to determine the patency of the carotid arteries.
Ophthalmodynamometry may be per- formed either by pressure on the globe or by suction. '■> With the ophthalmoscope the physician observes the point at which pul- sations begin in the retinal arterioles; this reading indicates the diastolic pressure. The procedure is continued until the retinal ves- sels cease to pulsate; this reading indicates the systolic pressure. A signihcant difference in the values of the two sides indicates impending carotid obstruction.
Treatment consists of the administration of anticoagulant drugs before the carotid artery becomes occluded. If necessary, sur- gical intervention may restore normal blood flow to the brain and eye.
Ocular Toxicity of Drugs
Numerous drugs have a toxic effect upon the eye either when applied topically or when used systemically. The harmful effects of prolonged local applications of common- ly used eye drops which are generally con- sidered harmless has long been known. This is especially true when the epithelium has been denuded by trauma or extrusion as a result of an infection.
In most cases, a physician is well advised to treat a simple corneal abrasion due to trauma by merely lavaging the eye, apply- ing a patch, and observing the eye daily. In many instances the eye usually heals without further treatment. On the other hand, repetitive applications of eyedrops in the presence of an epithelial defect may inhibit healing and cause permanent scar- ring. Drugs that inhibit healing and pro- duce permanent scarring in the presence of a corneal abrasion include topical anes- thetics, silver proteinate, zinc sulphate, sul- fonamides and antiviral agents.
The physician should be especially cau- tious when prescribing eye drops contain- ing corticosteroids because their prolonged use may lead to increased intraocular pres- sure or precipitate an acute attack of her- pesvirus keratitis. It is also known that long- term application of certain miotics may produce lens opacities. Finally, alpha chy- motrypsin, which is used by some in cata- ract surgery, may cause glaucoma and clouding of the cornea.
Systemic drugs. The prolonged systemic use of corticosteroids may produce cata- racts. Optic atrophy and loss of vision has followed the use of quinine. Chloroquine, used in the treatment of malaria, arthritis- and lupus erythematosus may be deposited on the corneal epithelium. Frequently a more serious and irreversible complication in the form of pigmentary degeneration of the retina occurs. Common psychotherapeu- tic agents such as the phenothiazine drugs may produce retinal changes as well as de- posits on the cornea and lens. Digitalis in- toxication producing blurred vision and central scotomas has been reported; recov- ery follows the discontinuance or reduction of the cjuantity. Oral contraceptives have been reported to have a significant relation- ship to thrombophlebitis in the legs and elsewhere and have been frequently associat- ed with pulmonary embolism. Less known
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Illinois Medical Journal
are the ocular complications either as a re- sult of cerebrovascular accidents or a result of neuro-ocular involvement producing optic neuritis and extra-ocular muscle pa- resis tv'ith diplopia. Ethambutol, a drug used in the treatment of pidmonary tuber- cidosis, may produce involvement of the neuro-optic pathways.
Chemical Burns
In these days of violence chemical burns of the eye are becoming more common. Mace, used by law enforcement officers, can cause chemical burns of the eye. Intentional or accidental alkali and acid burns call for immediate emergency measures. The victim should immediately flush the eye with water or any inert fluid that is available, such as milk, to remove the chemical agent. The time interval that elapses before la- vage is performed is frequently the most important factor that determines the de- gree of damage that follows a chemical burn. The author treated a woman who had been burned by lye deliberately thrown into her eyes. She had the presence of mind to reach for a milk bottle on a nearby door- step. She poured the contents into her eyes within a matter of seconds. Undoubtedly the immediate washing out of the toxic material contributed to the lack of per- manent damage.
It is generally known that alkalies cause far more damage to the eye than acids. Since it is also known that it requires a longer period of time to restore the normal pH of the cornea, washing with water (or- dinary tap water will do) should be carried on for at least thirty minutes. Further treatment depends upon the amount of damage sustained by the cornea, conjunc- tiva and the lids. Necrosis of these tissues frequently recjuires special therapy includ- ing surgical procedures.
Eyeliner applied to the lashes by women causes a chronic conjunctivitis and pigmen- tation of the conjunctiva. Biopsy of the pigmented conjunctiva shows microscopic- ally dense infiltration with lymphocytes and macrophages containing pigmented gran- ules.
Dyslexia
A deficiency or disturbance in the ability to read is termed dyslexia. Poor readers and children with true dyslexia are frequently
brought to the physician for examination and advice.
Ordinarily children learn to read either by recognizing an entire word (the “look- say” method) or by the arrangement of the individual letters and their sound (the “phonics method”). Some children use a combination of both methods to learn to read.
Dyslexia may be manifested in the fol- lowing ways:
1) The child cannot recognize the printed word, but he understands its meaning when the word is spoken;
2) The child recognizes and understands the printed word, but not the meaning when it is spoken;
3) The child recognizes individual letters but cannot put them together to form a word;
4) The child knows the word but cannot recognize the individual letters;
5) The child is able to read and under- stand the printed word and can hear and understand the spoken word, but he cannot associate one with the other.
The pediatrician confronted with a young child having reading difficulties should as- sume the leadership of a multi-disciplinary team comprising specially trained teachers, psychologists, and social service workers. The role of the ophthalmologist is to de- termine the presence or absence of ocular defects or abnormalities which might be contributing factors. The otologist and the psychologist should determine the status of the child’s hearing and intelligence. The social workers should search for family problems, disadvantageous cultural climate, poor teaching, or emotional disturbances that may play a role in the child’s reading deficiency.
Amblyopia
Strabismus or deviation of the eye pres- ent after the sixth month of life should be treated promptly if amblyopia is to be avoided. In unilateral deviation, the infant may use one eye to see and suppress vision in the other. In such instances, the squint- ing eye will not develop properly. Patching the good eye must be prescribed early to force the child to use the squinting eye to avoid irreparable damage.
Hubei and Wiesel recently demonstrated in the cat that occlusion of one eye caused
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a sharp reduction in the actual number of visual cells in the retina, the geniculate body, and the striate area of the cortex. Af- ter three months of occlusion, recovery or improvement did not occur.' Similarly an infant with a deviating eye and total sup- pression that is untreated until the child is 4 or 5 years of age will rarely have more than 20/200 visual acuity. On the other hand, a child with normal sight up to 6 or 8 years of age who develops a paralytic or non-paralytic strabismus retains his sight, no matter how long the eye remains de- viated. The physician must remember that a child does not outgrow a squinting eye and that very early therapy is necessary to avoid andrlyopia.
Emerging Developments in Ophthalmology
The dynamic nature of ophthalmology is nowhere more apparent than in the stream of new ideas and developments that are constantly being presented for considera- tion. Among the most noteworthy develop- ments, briefly mentioned, are:
• Ophthalmologists have begun to cjues- tion the belief of lighting engineers that “the most light is the best light.” Eye phy- sicians now report that over-illumination may be harmfid to the retina.
• Keratoprostheses. Patients almost blind from diseases of the cornea are treated by the imjilantation of an acrylic lens in the cornea. This frequently results in the res- toration of nsefnl vision.
• New methods to help the blind. New devices are being developed with the hope that the blind may regain 1) some measure of restored visual imagery or 2) some sub- stitute for sight. Principles involved are the use of radio receivers which are connected to electrodes in contact with the visual cor- tex or to substitute the skin’s sensory stim- uli for the lost visual stimuli.
• Retinoblastoma. Formerly malignant retinoblastoma in children was an indica- tion for early enucleation. Now with the aid of newer technicpies the eyeballs may be retained. This is especially important when both eyes are involved.
• Nonmagnetic foreign bodies which were previously impossible to remove from the eye are now being extracted by using low-temperature techniques. In this new procedure the tip of a low-temperature probe is placed in a position so that it comes in contact with the foreign body. The latter becomes fused to the cold tip and is withdrawn from the eye. If vitreous is lost and the eyeball is collapsed follow- ing a penetrating injury, eye surgeons may restore the fidlness of the eyeball by substi- tuting a balanced salt solution for the vitreous.
• Ophthalmologists as well as most other physicians have shown an increasing con- cern with the problem of automotive medi- cine. multidisciplinary approach to the jrroblem has already yielded information to help reduce the physical damage and to inqnove the treatment of patients involved in automobile accidents.
• Angiography. The injection intraven- ously of 5% solution of sodium fluorescein is now being used by many ophthalmol- ogists. The fluorescein dye aids in delineat- ing vascidar abnormalities, leakage from vessels, edema of the retina, abnormalities of the optic nerve disc, and in differentiat- ing microaneurysms from hemorrhages. M
References
1. Hubei. D. H. and ^Viesel. T. N,; “Receptive Fields, Binocular Interaction and Functional ■Architecture in the Cat's Visual Cortex," ]. of Physiologv 160:106, 1962.
2. Bellows, J.: “Molekulares V^orgehen zinn Me- chanisinus und der Behandlting der Herpes- virus-Keratitis." Klin. Monatshl. fiir Augeyi- lieilkunde 155:696. 1969.
S. Fabrykant, M., Gelfand, M. and Carter, G.: "Reversal of Hemorrhagic Diabetic Retino- pathv," Annals of Ophth. 2:96, 1970.
4. AVendland, J. P.: “Retinal .Arteriosclerosis in .Age. Essential Hypertension and Diabetes Mel- litus," Annals of Ophth. 2:68, 1970.
5. Radnot, M.: “Rheomacrodex (Dextran) in the Frcatment of the Occlusion of the Central Retinal Vein,” Annals of Ophth. 1:58, 1969.
6. Galin, M. et al: “Methods of Suction Oph- thalniodvnamometry,” Annals of Ophth. 1:439 1970.
7. Hubei D. H. and Wiesel, T. N.: “Electrophy- siology: Period of Suseptibility to Eve Closure Series Excerpta Meclica,” International Con- gress XXI Inti. Congress of Ophth., p. E3, March, 1970.
186 to 8 to ?
It took 186 years from the Declaration of Independence until 1962 before our Federal Government spent $100 billion in one year. But it took only eight more years for the annual budget to rise a second $100 billion, up to $200 billion.
54
Illinois Medical Journal
Counter-Measures Against Narcotic Addiction
Parents must confront each of their ado- lescent children with the dangers of taking narcotics. Dr. D. W. Winnicott, a British psychiatrist, recently has stated that adults are derelict in their duty if they ignore or lamely submit to the attitudes of the pres- ent generation of adolescents. Confronta- tion can be a valuable technique parents need in facing the tidal wave of drug addic- tion that threatens to innundate the pres- ent generation. Confrontation techniques have been extensively studied by Dr. Harry Garner, head of psychiatry at Chicago Med- ical School. The confrontation technique involves the use of a strong, positive ex- clamatory sentence followed by a question. - An example would be “I never want you to take narcotics.” “What do you think or feel about what I’ve told you?” Hopefully this will stimulate the pre-adolescent to listen and to discuss the dangers of taking drugs and maintain a dialogue on the stdr- ject with his parents. It is most important that the confrontation begin in pre-adoles- cence, before the child has been exposed to the powerful “peer group pressure” of high school and college.
The National Institute of Mental Health has also been looking into more effective ways to change adolescent attitudes toward the use of narcotics.^ The newly proposed program will no longer emphasize the ne- gative aspects such as the dangers and side effects of taking drugs.
The new approach is to show teenagers the stupidity of taking drugs and the ex- posure of addicts to ridicule. A spokesman for the agency in charge of the new cam- paign for NIMH states that as much as he dislikes slogans they may be effective in modifying adolescent attitudes. He sug- gested, as a possible slogan: ‘AVdiy do you think they call it dope?” To this rather weak effort we can add “Don’t be an ass; Keep off grass.” “Don’t be duped by dope.” “Would you want your appendectomy done by a speed taking surgeon?” ‘AVould you fly with an airline pilot high on LSD?”
Picture the following statement as a pos- sible poster. “Don’t be duped, tricked, rooked, badgered, led, misled, forced, bribed, trapped, lured, enticed, enchanted, euchered, talked, ensnared, bamboozled, coerced, cajoled, fooled, flattered, deceived.
hood-winked, challenged, harassed, bluffed, coaxed, shamed, teased, tantalized, manipu- lated, bulldozed, pressured, persuaded, hounded, pestered, seduced, terrorized, blackmailed, threatened, driven, pushed, in- veigled, nagged, cozened, suckered, goaded, railroaded, beguiled, induced, into taking
dope.”
The use of these slogans can only be the beginning of the battle against the spread of narcotic addiction. A campaign similar to the highly successful one the American Cancer Society has developed is urgently needed. Local communities should con- sider conducting, with students and civic organizations, an anti-drug abuse day.
The medical profession should join with government agencies, private foundations, large corporations and the communications media in launching a coordinated counter- attack against the insidious spread of drug addiction in the LInited States.
Harvey Kravitz, M.D.
References
1. ^VinnicoU. D. \V.. “.Adolescent Process and the Need for Personal Confrontation.” Pediatrics 4:752, 1969.
2. Garner. H. H., “The Confrontation Problem Solving Technique: Developing a Psycho-Thera- petitic Force.” American Journal of Psycho- therapy 24:27. 1970.
3. Sanford, D., “Unselling Drugs,” New Republic. February 28, 1970, p. 15.
Pulmonary Function Evaluation
Many tests are available for evaluating pulmonary function. The majority of these procedures are sophisticated and best per- formed by physicians specially trained in pulmonary physiology. In recent years, the demand for these tests has increased due to
for July, 1970
the hish incidence of chronic bronchitis and emphysema. Cigarette smokers with a chron- ic cough or dyspnea shonid have pulmon- ary function studies made as part of their total health evaluation. The procedures may provide the dehnite objective evidence that will encourage the smoker to quit.
How much pidmonary function equip- ment should the clinician buy for his of- fice? For those who are not specialists in chest diseases, a spirometer is the only piece of equipment that is needed. The patient shoidd be referred to the pidmonary labora- tory if more extensive tests are needed. Many types of spirometers are available; the quality is in proportion to the cost. The most satisfactory are sturdily construct- ed, have a low apparatus resistance, and are convenient to use. The paper speed should be sufficient to make accurate mea- surements.
Spirometry determines restrictive and ob- structive types of ventilatory insufficiency. The restrictive type is due to loss of ventil- able lung tissue resulting from inflamma- tion or fibrosis. Loss of lung parencliyma may also stem from destruction or resec- tion of lung tissue, heart failure, or chest wall disease. Parenchymal changes also oc- cur in emphysema and parallel the loss of
elastic recoil of the lungs as the destructive process progresses. The vital capacity is measured by having the patient inhale as deeply as possible and exhale slowly into the machine until there is no further flow. This value is compared to that of normal individuals of the same age and height.
Obstructive ventilatory insufficiency usu- ally results from asthma, bronchitis, or em- physema. There is an increase in the resist- ance to air flow within the bronchial tree. The forced vital capacity (FVC) is obtained by exhaling rapidly and forcibly to the point of no flow. Many measurements can be obtained from this curve which are then compared to predicted values. Maximum voluntary ventilation (MW) can also be obtained by having the patient breathe as vigorously and rapidly as possible for 15 seconds. In this way the volume exhaled during three or more breaths is recorded. This is checked against known standards.
The spirometer is not infallible and the results should always be correlated with clinical findings. This is understandable be- cause the results are influenced by the pa- tient’s volitional efforts. All of these factors must be considered to avoid overdiagnosis
O
of respiratory diseases.
T. R. Van Dellen, M.D.
Search for Metabolic Lesion
The exact metabolic lesion in cystic fibrosis has not yet been discovered. Approximately one of every 2,000 persons born in the United States is afflicted with this generalized disorder of exocrine glands, characterized by excessive mucus production and inability of the ducts of sweat glands to reabsorb sodium, chloride and potassium. Chronic pulmonary disease is responsible for most of the morbidity and mortality. A few of the pa- tients succumb to abdominal complications— in some cases as neonates with meconium ileus, in others later in life as a result of intestinal ob- struction or secondary to a characteristic; biliary cirrhosis. Attempts to ex- plain these striking and devastating clinical features have recently led to significant advances in knowledge, providing clues for the search for the metabolic defect in cystic fibrosis. (Richard C. Talamo, M.D., "Cystic Fibrosis of the Pancreas— New Clues to the Metabolic Riddle." California Medici.ie n0:5 [May] 1969.)
Suggestions Offered
Is the quality of service in your hospital, the efficiency of operation, and the well-being of patients less than desirable? Are there too many indif- ferent employees? This administrator offers some suggestions for a pro- gram to eliminate these and other problems. (Clyde T. Hardy, Jr.: "A Staff Meeting I Would Like to Attend." Physician's Management [June] 1969.)
56
Illinois Medical Journal
illinois state medical society may 17-20,1970 Sherman house, Chicago
Highlights of Convention Elections
Actions of House Delegates
1970-1971 OFFICERS AND BOARD OF TRUSTEES
Officers
President President-elect 1st Vice-President 2nd Vice-President Secretary-Treasurer
J. Ernest Breed, 55 E. Washington St., Chicago 60602 L. T. Emin, 5 Citizen’s Square, Normal 61761 George Shropshear, 1525 E. 53rd St., Chicago 60615 C. J. Jannings III, 101 E. Center St., Fairfield 62837 Jacob E. Reisch, 1129 S. 2nd St., Sjjringfield 62704
House of Delegates
Speaker of the House Paid W. Sunderland, 214 N. Sangamon St., Gibson City 60936 Vice-Speaker Andrew J. Brislen, 6060 S. Drexel Blvd., Chicago 60637
Trustees
1st District 1971
2nd District 1971
3rd District 1971
1971
1972
1972
1973 1973
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Joseph L. Bordenave, 1665 South St., Geneva 60134 VVhn. A. McNichols, Jr., 101 W. 1st St., Dixon 61021
William M. Lees, 6518 N. Nokomis, Lincolnwood 60646 Frank J. Jirka, Jr., 1507 Keystone Ave., River Forest 60305 Warren W. Young, 10816 Parnell Ave., Chicago 60628 Eredric D. Lake, 1041 Michigan Ave., Evanston 60202 James B. Hartney, 410 Lake St., Oak Park 60302 Frederick E. \\A4ss, 15643 Lincoln, Harvey 60426
Fred Z. White, 723 N. Second St., Chillicothe 61523 A. Edward Livingston, 219 N. Main, Bloomington 61701
Mather Pfeillenherger, State & Wall Sts., Alton 62002 Arthur E. Goodyear, 142 E. Prairie St., Decatur 62523 Eugene P. Johnson, 22 W. Main St., Casey 62420
Charles K. Wells, 117 N. 10th St., Mt. Vernon 62864 Willard C. Scrivner, 4601 State St., E. St. Louis 62205 Joseph R. O’Donnell, 444 Park, Glen Ellyn 60137
T rustee-at-Large
Edward W. Cannady, 4601 State St., E. St. Louis 62205
Chairman of the Board Willard C. Scrivner, 4601 State St., E. St. Louis 62205
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Illinois Medical Journal
CONVENTION HIGHLIGHTS
Addressing the House of Delegates was Dr. Edwanl W. Cannady, ISMS president.
ATTENDANCE TOTALS
Attendance at the 130th Annual Meeting was as follows:
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Physicians |
1.516 |
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Guests |
256 |
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Auxiliary |
242 |
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Exhibitors |
347 |
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Medical Students |
76 |
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Allied Health Personnel |
260 |
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Total |
2,697 |
AD HOC REFERENCE COMMITTEE ADDED
A new and special reference committee was added this year to enable medical students to express their views and opinions.
MEMORIAL SERVICE HELD
Jacob E. Reisch, M.D., ISMS secretary-treasurer, con- tlucted a brief memorial service for the 172 deceased ISMS members. For the first time this past year personal notes of condolence were sent to families of deceased members from ISMS.
SAMA OPINIONS EXPRESSED
Lee Fischer, medical student and SAM,\ Midwest Re- gional Vice-President, the University of Illinois, addressed the House and reviewed S.\M,\’s involvement on the medical scene. Mr. Fischer expressed the concern S.-\M.\ members feel over the relevancy of such projects as MECO and better health care, compared to the ellort spent on the war. In directing his remarks to the House, Mr. Fischer asked that students not be ignored if they are to work together with members of ISMS in solving prob- lems of health care for all the people.
IMAA PRESIDENT REPORTS TO THE HOUSE
Miss Ina Yenerich, president of the Illinois Medical Assistants Association, reviewed the past year’s activities and cited the increase in membership dtie to the work- shops sponsored in conjunction with the President s Totir. .She condtided her remarks in noting that the patients will benefit most from close coordination between doctors and medical assistants.
MRS. ARNOLD REVIEWS AUXILIARY'S PROGRESS
Mrs. Sherman Arnold, president of the Woman's ,\tixi- liary to the ISMS, cited the primary objective of the Auxiliary as supporting the ISMS program. .Atixiliary participation in the President’s Tour was the highlight of the past year. In behalf of the 3,100 members of the .Auxiliary, Mrs. Arnold presented to Dr. Cannady, a check in the amount of ,|7, 934.09 for Benevolence.
DR. THOMSEN GIVES IMPAC REPORT
Dr. Philip Thomsen urged members of the House to identify and offer solutions to the social, economic and medical proltlems Itesetting doctors before they lead to government intervention. Physicians should cooperate with the government in providing medical leadership. They shoidd also particijrate in political campaigns through financial contributions and campaign manpow'er.
He discussed IMPAC's ellectiveness and tirged more doc- tors to join IMP.AC, especially from Cook Cotnity where the participation is less than from other cotinties. He noted that of the 369 legislative bills presented in Illinois this past year, 90 were Itills directly affecting physicians and medicine, which once again emphasized IMPAC's necessity on the legislative scene.
ISMS PRESIDENT'S REPORT
Dr. Edward Cannady commented on his role as chief spokesman of I.SMS on problems stich as rising costs of health care, training and keeping more doctors in Illinois, and alleviating the doctor shortage by sponsoring and stipporting legislation establishing a Department of Fam- ily Medicine at the I’niversity of Illinois. He also cited ISMS’s role in sectning a state appropriation for medical school expansions, including |6 million to the Chicago Medical .School which will dotible the school’s enroll- ment. The Society also stipported creating a medical school for Sotithern Illinois University and other schools in the downstate area.
Dr. Cannadv urged physicians to vote in favor of an independent Council on Contintiing Medical Editcation and called for support of the medical profession in other programs to provide effective and economical health care.
Dr. Philip Thomsen, chairman of the IMPAC Board, addresses his remarks to the delegates at the first session of the House.
for July, 1970
59
Dr. Leon O. Jacobson, dean, Pritzker School of Medicine, The University of Chicago, ac- cepts a check on behalf of Illinois’ five medical schools from President Edward W. Cannady. The check, in excess of $120,000, was con- tributed by ISMS members as designated AMA- ERF dues.
DR. CANNADY PRESENTS AMA-ERF FUNDS
Approximately $120,000 representing the total AMA- ERF collection for Illinois Medical Schools was presented to Dr. Leon Jacobson, dean, Division of Biological Sci- ences, Pritzker School of Medicine, University of Chicago, for distribution.
EDMUND F. FOLEY ACCEPTS HAMILTON TEACHING AWARD
Dr, Edmund F. Foley, emeritus professor of medicine, Fhiiversity of Illinois College of Medicine, received the Hamilton Teaching Award for his outstanding quali- ties as a teacher of medical students. A plaque and $500 cash award was presented to him by Dr. George B. Calla- han, a member of the Board of Trustees of the Inter- state Postgraduate Medical Association.
Mrs. Sherman Ar- nold, president, the Woman’s Auxiliary to ISMS, speaks to the House of Delegates at the ISMS annual meet- ing.
DR. MORRIS FISHBEIN ADDRESSES 50 YEAR CLUB LUNCHEON
Dr. Morris Fishbein, w'orld-famous author and former editor of JAMA compared today’s medical students with those of his day, noting the striking similarities. In ad- dition, 39 new members were initiated into the club and presented with awards by Dr. Edward W. Cannady.
J. ERNEST BREED INDUCTED AS PRESIDENT
Dr. J. Ernest Breed was inducted as president of the ISM.S at the third House of Delegate’s session. Administer- ing the oath of office was outgoing president. Dr. Edward W. Cannady.
Afterward, Dr. Breed presented his inaugural speech emphasizing:
Immunization programs for needy pre-school children;
Group practice in rural areas;
Peer Review;
Malpractice and
Continuing medical education.
In summation Dr. Breed said, “My aspiration for the year ahead revolves around 'how can we make things happen?’— not ‘what is happening to us’?’’
POLITICAL SATIRIST ADDRESSES PUBLIC AFFAIRS DINNER
Art Buchwald, satirist and newspaper columnist, de- livering the Camp Memorial lecture, delighted those in attendance at the Seventh Annual Public Affairs Dinner in speaking on “The Establishment Is Alive and Well and Living in Washington,” U. S. Senator Ralph T. Smith was also present at the dinner and spoke briefly on current problems being contemplated by the U.S. Congress.
PRESIDENT'S BANQUET A HIGHLIGHT OF CONVENTION
The premier social event of the convention— the Presi- dent’s Reception and Banquet— was held on Tuesday evening, honoring Dr. Edward W. Cannady for a highly successful year as ISMS president. Entertainment was pro- vided by the Frankie Masters Orchestra and songstress Grace Markay.
The Hamilton Teaching Award was presented to Dr. Edmund F. Foley, (right) professor emeritus of medicine, from the University of Illinois College of Medicine, by Dr. George B. Callahan, trustee of the Interstate Postgraduate Medical Education Association.
COUNTY MEDICAL SOCIETIES RECOGNIZED FOR IMMUNIZATION PROGRAMS
Dr. P'ranklin D. Yoder, director, Illinois Department of Public Health, commended the trustees for their sup- port in developing immunization programs. Special em- phasis has been placed on vaccinating susceptible indi- viduals such as pregnant women as well as children in kindergarten through third grade. He commended the manv county societies which have conducted immuniza- tion programs.
AMA PRESIDENT-ELECT COMMENTS ON AMA SCENE
Dr. Walter C. Bornemeier announced that two, 30 minute documentaries are being produced by the AMA
Dr. Edward W. Cannady, past-president from East St. Louis, pauses to admire the President’s Medallion he has just presented Dr. J. Ernest Breed, at the closing session of the ISMS an- nual meeting.
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Illinois Medical Journal
Feted at the Annual Past Presidents’ Dinner, for 34 years with ISMS, was Mrs. Frances C. Zimmer, executive assistant. (Standing from left), Drs. Arkell M. Vaughn, Caesar Portes, Edwin S. Hamilton, Edward A. Piszczek, George F. Lull, Harlan English, Philip G. Thomsen, H. Close Hesseltine, Newton DuPuy, Jacob E. Reisch (host). Seated, Dr. Everett P. Coleman, Mrs. Zimmer, Dr. James H. Hutton.
to counteract the biased programs on health care pre- sented by the CBS network.
He forecast the partial alleviation of the doctor short- age with the opening of new medical schools and called attention to current residency programs which do not prepare physicians to care for the sick outside of hospitals.
SCIENTIFIC EXHIBIT AWARDS PRESENTED TO EXHIBITORS
Gol*. Award— The Anatomic Basis of Groin Hernia Repair,
Robert E. Condon, M.D., Depart- ment of Surgery, University of Illinois, College of Medicine. Silver Award— A Demonstration of Normal Tem- poral Bone Anatomy and the His- topathology of Common Inner Ear Disorders.
John R. Lindsay, M.D.,
Horst R. Konrad, M.D., Midwestern Temporal Bone Banks Center.
Bronz Award— Subtraction Technicjue with Color Addition.
A. K. Bonk, M.D.
Edgewater Hospital
1st Vice President 2nd Vice President Sec'y-Treas.
Speaker of the House \'ice Speaker Trustees elected were: 3rd District 3rd District 4th District 5th District 7th District 8th District
George Shro]5shear, Chicago C. J. Jannings III, Fairfield Jacob E. Reisch, Springfield Paul ^V. Sunderland, Gibson City .Andrew J. Brislen, Chicago
James B. Hartney, Oak Park Frederick E. W'eiss, Chicago Fred Z. White, Chillicothe A. Edward Livingston. Bloomington Arthur F. Goodyear, Decatur Eugene P. Johnson, Casey
AMA DELEGATES ELECTED
Members of the AMA Delegation elected for two-year terms beginning January 1, 1971, were Maurice M. Hoelt- gen, Francis \V. A'oung, H. Close Hesseltine, Carl E. Clark and Joseph R. Mallorv. .Alternate delegates elected were Theodore VanDellen. Fred .A. Tworogcr, Frank J. Jirka, Jr., Joseph O'Donnell and Jack Gibbs.
Harold .A. Sofield w'as elected to serve the unexpired term of Walter C. Boniemeier as delegate, to take office immediately. Alternates elected to hll unexpired terms were Boyd McCracken, Glen Tomlinson, Herschel L. Browns and AVilliam M. Lees.
NEW OFFICERS ELECTED FOR 1970-1971
Fhe House of Delegates elected the following officers and trustees:
President elect L. T. Fruin, Normal
Dr. R. Kent Swedlund, Watseka, the first to register at the 130th annual meeting, was greeted by staff member, Betty Lynch.
The Gold Scientific Award was given to Dr. Robert E. Condon, from the Department of Surgery, University of Illinois College of Medicine for his exhibit, “The Ana- tomic Basis of Groin Hernia Repair.”
for July, 1970
61
Art Buchwalcl, political satirist and columnist was the center of attention after his humorous presentation of “The Estahlishment Is Alive and Well and Living: in Washington,” at the Seventh Annual Public Affairs Dinner. Meeting the speaker were (from left). Dr. Paul Theobold, Dr. L. T. Fruin, Art Buchwald, Dr. Theo- dore Grevas, and Tony Holloway, Journalism Fellowship recipient.
STAFF HONORED
Janies Shuvny, director. Division of Public Relations and Economics, received a placjue in recognition of initia- tive, originality and outstanding achievement in pidilic relations programming.
Mrs. Frances C. /iminer also was honored with a phupie in recognition of her 34 years of service to I,S\fS,
HOUSE TACKS $2 ON DUES
The House accepted the recommendation of the Board of Trustees that the 1970 dues remain unchanged at .S105. However, upon recommendation of the Reference Com- mittee on Education &: C-ommunitv Health .Services, the House approved a special one-year assessment of .‘52 to
cover the production and mailing cost of sending the lUinnis Medical ]ournal and Pulse to all SAMA members attending Illinois Medical Schools.
REFERENCE COMMITTEE CHAIRMEN
Constitution & Bylaws O.'licers it ,\dmin;stration Finances. Budgets & Publications
Legislation & Public .Affairs Education It Community Hi
Glen E. Tomlinson, Lincoln Charles U. Culiner. Waukegan Francis W. Young, Chicago
C'.harles N. Salesman, Robinson Lawrence L. Hirsch, Chicago
Services
Econoni'cs it Social Services R. K. Swedlund, Watseka Public Relations & Misc. Bus. Fred Tworoger, Chicago ,\d Hoc Robert E. Heerens, Rockford
Fifty Year Club members gathered together for a group picture were (from top left), Drs. Carl F. Steiiihoff, Proctor C. Waldo, Raymond S. Shurtleff, Max F. Fngerman, Peter J. Werner, Joseph J. Litschgi, Norbert Pauker, (bottom, from left) Arthur R. Bogue, Woodruff L. Crawford, Henry F. Heller, Charles A. Learsy, Samuel M. Feinherg, Ralph A. Reis, Robert M. Graham, George F. Irwin.
62
Illinois Medical Journal
SUMMARY OF ACTIONS OF THE HOUSE OF DELEGATES
I. REFERENCE COMMITTEE ON OFFICERS & ADMINISTRATION
The reports of Officers, Trustees, Chairman of the Board of Trustees, AMA Delegation, Executive Admin- istrator, Speaker, Vice Speaker, Auxiliary President and Advisory Committee to the Auxiliary were received and accepted, with commendation for outstanding service to the Society.
In accepting the report of the Policy Committee, it was suggested that the Board of Trustees review the policy statement on “Hospital Records and Their ,\vail- ahility” in light of the current hospital procedure for supplying photocopies of records on request of Medicare intermediaries and other third parties.
Reports of the Policy Committee, the Committee on Committees, Committee to Study Osteopathic Problems and the Ethical Relations Committee were also accepted by the House.
IMPLEMENTATION OF PHYSICIANS LIABILITY PROGRAM
Resolution 70M-34 was adopted, which provides for the implementation of the program developed by the Physicians Liability Evaluating Committee. The ])rogram will involve a state- wide program on how to avoid mal- practice suits and assistance to physicians threatened with
suits. The details of the program are subject to approval by the Board of Trustees.
INCREASED BOARD REPRESENTATION & JOINT MEETINGS
■■\cting upon a special amended report, the House ap- proved the following:
A fifty percent increase in representation on the Board of Trustees from the 3rd District and no change in the composition of the House of Delegates.
That the House of Delegates direct negotiations aimed to bring about prompt amalgation of the annual scientific meetings of the ISMS and of the Chicago Medical Society, and That the Constitution & Bvlaws Committee be instructed Now by the House of Delegates to submit the necessary recommended changes to the 1971 annual meeting of the House of Delegates. Under tlie change in representation the Board of Trustees will consist of 19 elected trustees (presently 16), four elected officers (with vote), anil two vice presidents and one vice sjjeaker (without vote).
II. REFERENCE COMMITTEE ON FINANCES, BUDGETS & PUBLICATIONS
1 he House accepted reports sidjmitted by the Educa- tional & Scientific Eoundation, Publications Committee, Editorial Board. Editor of the IMJ> tlie annual audit and the Treasurer’s Report. It also approved the report of the Benevolence Committee which included increased payments to a majority of recipients.
PROJECTED 1971 BUDGET
The House approved the Reference Committee recom- mendation that $6.50 per each dues paying member be deducted from the previous $8 allocation to the Per- manent Reserves and be placed in the General Operating Eund to l)alance the 1971. projected budget. The House approved distribution of the dues dollar for 1971 as
follows:
Operating Eund $77.50
Permanent Reserves 1.50
AMA-ERE 20.00
Benevolence 4.00
HCCI 2.00
$105,00
Special assessment Publication, production and mailing IMJ
for S.AMA members 2.00
Total $107.00
In other specific action the House of Delegates: Passed a resolution authorizing the Board of Trustees to request that all undesignated .AM.A-ERF funds from ISMS dues allocation be equally divided among Illinois medical schools.
Rejected a resolution requesting that the $8 allocation designated for the reserve fund be iliscontinued and instead be placed in a special fund for utilization in developing or implementing new programs recommended by the House.
Rejected a resolution calling for a dues increase, of which a certain amount would be allocated to finance SAMA activities and to reimburse those county medical societies with an executive office and staff.
■Adopted a revised resolution asking the .AM.-A delegates to introduce a resolution in the ,AM.A House of Delegates requesting that the JAMA return to its former policy of omitting advertising from the editorial and scientific pages of the JAMA.
Rejected a resolution authorizing that all undesignated .AM.A-ERF funds from the ISMS dues alloca- tion be awarded as a yearly prize to the medical school which has shown the greatest effort in increasing the number of Illinois physicians who go into private practice in rural communities and depressed citv areas.
III. REFERENCE COMMITTEE
PEER REVIEW
Approval was given to the establishment of peer re- view under the Bylaws. Each component society shall have, by appointment or election, a Peer Review Com- mittee whose duty it shall be to review all proper com- plaints and inquiries brought before it by physicians, patients, institutions, insurance carriers or government
ON CONSTITUTION & BYLAWS
agencies. The district peer review committee shall func- tion on behalf of any county society which does not es- tablish such a committee or elects not to function.
The committee shall consist of a chairman and such members representing both general practice and various specialties as each individual county society shall deter- mine. Reasonable rules and operational procedure shall
for July, 1970
63
be established by the component society. The State So- ciety committee will act upon appeals from the decisions of the county or district committees.
SAMA REPRESENTATION
Ihider the new Bylaws S.AMA will be entitled to one delegate and one alternate delegate to serve in the House of Delegates, with full membership and voting privileges.
AMA DELEGATES ON COUNCILS OR COMMITTEE’S
Favorable action was taken on the resolution to permit AMA delegates to serve as chairmen or members of any council or committee. Voting members of the Board of Trustees may serve only as advisory members to any council or committee.
SEATING OF DELEGATES
Of particular significance for the 1971 annual meeting was the adoption of change in the principle of seating alternate delegates during the House of Delegate sessions. If a seated delegate is replaced by an alternate, he may not be seated again for that session, but he may be seated at subsequent sessions.
In other actions taken the House:
Referred to the Board of Trustees a resolution requesting affiliate status for the Illinois Chapter of the .American College of Radiology and that such
IV. REFERENCE COMMITTEE ON
The reports submitted liy the Council on Economics and Governmental Health Programs, Council on Social and Medical Services, Committee on Disaster Medical Care and the Committee on Prepayment Plans and Organiza- tions were accepted.
VISITING NURSING SERVICE UNDER MEDICARE
A resolution calling for a better understanding by the Blue Cross Medicare fiscal intermediary and Social Se- curity .Administration relative to payment for visiting nursing service was not approved. The Flouse felt that this problem was due to a breakdown of communication and failure to comply with existing guidelines and offered several constructive suggestions.
ILLINOIS DEPARTMENT OF PUBLIC AID
The report of the .Advisory Committee to the Illinois Department of Public .Aid was accepted. The House ex- ]tressed appreciation for information regarding its func- tions and for its outline of recommendations made to the Department.
Harold O. Swank, director of IDP.A, called particular attention to:
(1) Payment for physical examinations and im- munizations of underprivileged children in first, fifth and ninth grades.
(2) Payment of psychiatric services outside of mental hospitals as a future possibility.
(3) Extension of “medical only” eligibility for a limited time to selected cases leaving public aid rolls.
(4) Extension of family planning services.
The report of the Sub-Committee on Drugs and Thera- peutics was also adopted.
DIVISION OF VOCATIONAL REHABILITATION
The Advisory Committee to the Department of Voca-
affiliation entitle the chapter to representation in the House of Delegates.
Referred to the Board for further study a proposed change in the Bylaws which would establish af- filiate societies wdth voting representation in the House.
Adopted an amended resolution which established the policy that the Committee on Committees shall function at the request of the Board rather than annually, to review and report on the com- mittee structure.
Referred to the Board of Trustees the proposed amend- ments that the House of Delegates be the state society forum to set the philosophy of the So- ciety: and
Referred to the Board of Trustees a resolution giving the House of Delegates authority to direct the Board of Trustees to spend funds for the im- plementation of programs.
•Approved in principle a resolution to permit county medical societies to seek reimbursement from third party organizations for expenses incurred through peer review activities.
•Adopted a resolution calling for ISMS to support the principle that county medical society peer re- view committees be the first source of appeal from decisions made by hospital or other medi- cal facility review' committees.
ECONOMICS AND SOCIAL SERVICES
tional Rehabilitation was cited for its effects to establish an initial liaison with DVR. The recommendations of the 1969 House of Delegates calling for the establishment of guidelines to determine eligibility, and emphasizing referral to the DA'R program by a physician was reaf- firmed.
4 he Reference Committee recommended and the House of Delegates concurred, in requesting an investigation to determine the possibility of over-utilization of this pro- gram and tile qualifications for eligibility. This matter shotdd lie stibmitted to the .Advisory Committee on Me- dical Costs and EUilization of Services created by SB 1139, Illinois 76th General .Assembly.
AGING
The report submitted by the Committee on Aging was accepted. Qtiestions concerning intraveneous treatments, collection of blood specimens for tests, and death certifi- cation raised by the Committee on Aging, were referred to the ISMS Medical Legal Cotindl.
NURSING SCHOOL CElRTIFICATION The recommendation of the Committee on Nursing that certification of college-level medical paramedical edu- cational ctirrictda be transferred from the Department of Registration and Echtcation to the appropriate governing board, w'as approved.
HEALTH CAREERS COUNCIL
Based on the report of the .Advisory Committee to Paramedical Groups the House agreed that the financial support currently being given to the Health Careers Council, be continued at $2 per dues paying member.
The recommendation that the physician liaison mem- ber to the Health Careers Council should be a member of the Advisory Committee to Paramedical Groups was also accepted.
64
Illinois Medical Journal
HOSPITAL REIMBURSEMENT
Resolution 7M-50, calling for Blue Cross and the De- partment of Public Aid to use prospective rate negotia- tion as the method of hospital reimbursement, was adopted. The substance of this resolution will be sub- mitted to the House of Delegates of the AMA when it convenes.
USUAL AND CUSTOMARY FEE COMMIHEE
The report of the Usual and Customary Fee Committee was adopted, including the request that county medical societies embrace the full range of fees of all physicians in the area as delineated by the usual, customary and reasonable definitions, in lieu of fee schedules or coeffi- cients applied to relative value scales.
In specific actions taken on resolutions reviewed by this Reference Committee, the House:
Reaffirmed the concept of a contractural relationship exist- ing only between the physician and patient, the necessity for consultation paid for by the insurance carrier, and the acceptance of physi- cians’ fees which are “usual and customary,” without implication of any overcharge as basic policies of the ISMS.
Rejected a resolution calling for the elimination of the Drug Manual prepared by the Sub-Committee on Drugs and Therapeutics.
Rejected a resolution seeking ISMS endorsement of the Attending Physician's Statement-Health Insur-
ance Claim-Group or Individual form as the only claim form to be completed by ISMS phy- sicians after January 1, 1971.
Adopted, as amended, a resolution that, after January 1, 1971, a representative of a group, clinic, or corporation may sign the Illinois Department of Public Aid claim form with the attending physician’s name appearing on the claim form.
Adopted, in amended form, a resolution that ISMS en- courage county medical societies to establish medical review committees, including utiliza- tion review in long-term care institutions.
Adopted a resolution suggesting liaison between medical societies and hospital boards of directors by recommending to the AMA House that a pub- lication such as the American Medical News be sent to each hospital board member, and that hospital staffs be encouraged to purchase individual subscriptions for hospital board members.
.Adopted a resolution calling for ISMS, other societies in the Chicago area, and the AM.A, to establish and operate a facility in the City of Chicago to provide medical services to disadvantaged and minority groups.
Rejected a resolution calling for updating the ISMS “Re- lative Value Study, ” preferring to rely on usual, customary and reasonable fee definitions as the acceptable method of adjudicating fees.
V. REFERENCE COMMITTEE ON PUBLIC RELATIONS & MISCELLANEOUS BUSINESS
The report of the Council on Public Relations and Membership Services, including a report on the Physician Placement Service, was accepted. Reports of the Commit- tee on Medicine and Religion and the Task Force on Physician Shortage and Services to Medically Deprived Areas, were likewise accepted.
In accepting the report of the Committee on Insurance, it was noted that over 1,100 physicians are now insured under the professional liability insurance program.
PUBLIC RELATIONS PROGRAMS
The House endorsed the Reference Committee’s citation for excellence of the public relations programs on rising health costs and the ISMS response to the Senate Finance Committee report on Medicare and Medicaid. The recom- mendation that consideration be given to increasing the Public Relations Division staff, if increased public rela- tions services are required by the membership, was approved.
A resolution requesting that ISMS document cases in Illinois of residents unable to obtain proper health care, and then propose a solution for the problem, was rejected.
A resolution criticizing the ISMS public relations pro- gram for failure to project the viewpoint of the private practicing physician and a request for reorganization of the public relations program was also rejected.
MEDICARE, MEDICAID AUDIT AND PUBLICATION OF FACTS
A substitute resolution was adopted in lieu of two sep- arate resolutions calling for an audit of the administra- tive costs and expenditures under the Medicare and Medi- caid programs and a public information campaign ini- tiated, based upon these findings. The adopted substitute resolution recognized that a distorted picture exists as to the adequacy of health care in the United States,
the reasons behind the expense and short comings of the Medicare-Medicaid programs and called for ISMS to continue to publicize the physician’s share of the health care dollar received under the Medicare and Medicaid programs.
PRIVATE MEDICAL CARE VERSUS GOVERNMENT CARE
A substitute resolution was adopted to replace one calling upon the ISMS to urge AMA to develop a pro- gram to promote the present medical care system, includ- ing a “Truth Squad" to shadow HEW and to correct improper and incorrect statements in the news media. The substitute resolution expressed criticism of the AMA for failure to convey the positive aspects of private medi- cal care to the public, castigated those who propose com- pulsoi7 national health insurance and a complete change in the system of health care delivery and called upon the ISMS to urge the AMA to further amplify its efforts in promoting the private practice of medicine. The program to be developed should be directed to both the public and to physicians.
In other actions, the House of Delegates:
Approved implementation of a study of the important relationships between medicine and religion and seminars to be held in various areas in Illinois during 1970 under auspices of the ISMS Committee on Medicine and Religion.
Affirmed the right of the public to protection from un- warranted medical statements appearing in the news media or made by those in government who have misrepresented facts without concern for the health or welfare of human beings— the ISMS Public Relations program to inform the people of Illinois of this policy— the delegates to the AM.A, to introduce this principle into the AMA House of Delegates.
for July, 1970
65
Adopted a substitute resolution approving the concept of a National Academy of the Health Professions —that the study of the delivery and cost of health care, subsequently followed by appro- priate planning, be the primary concern of the Academy— that detailed reports be made to the
AMA House of Delegates at appropriate in- tervals.
Rejected a resolution which referred to the Himler Re- port and pertained to the wasteful use of man- power and the method for electing directors to the proposed National Academy of Health Professions.
VI. REFERENCE COMMUTEE ON LEGISLATION & PUBLIC AFFAIRS
Reports of the Council on Legislation and Public Af- fairs, Committee on Public Affairs, Task Force on Com- prehensive Health Planning, Eye Health Committee, Im- partial Medical Testimony Committee, Laboratory Serv- ices Committee and the Committee on Licensure, were accepted.
The initial report of the Medical Legal Council was accepted but that portion of the supplementary report dealing with limits on nurses services in nursing homes, was referred back to the Medical Legal Council for fur- ther study and clarification.
PHYSICIAN LICENSURE
The Reference Committee’s recommendation that the major problem with respect to licensure appears to be a lack of communication between the applicants and the Medical Examining Committee, was accepted. Three of the four resolutions, dealing with examining procedures un- der reciprocity were referred to the Medical Legal Coun- cil and its Committee on Licensure for further study. An additional resolution calling upon the ISMS to use its resources in seeking to have the Board of Medical Exam- iners process applications for medical licensure by reci- procity or endorsement on at least a monthly basis when such applications are pending, was adopted.
LICENSING OF MENTAL HOSPITALS
A resolution was adopted which calls for the ISMS to seek changes in legislation or administrative regulations to provide for licensing of mental health facilities. The action calls for:
“Those services of the Illinois Department of Mental Health which correspond to services offered by private psychiatric hospitals, gen- eral hospital psychiatric units and sheltered care facilities be subject to the same mini- mum standards (sic— as other hospitals), so that appropriate parts of all health care fa- cilities in the state can be licensed by the De- partment of Public Health.”
INCREASED TUITION FEES
An amended resolution was adopted regarding increase in tuition fees to the University of Illinois students. The substitute resolution provides that the ISMS, through its Division on Legislation and Public Affairs work during the upcoming session of the state legislature to lower the tuition structure as recommended by the Governor.
PUBLIC AFFAIRS— AMPAC
The House adopted an amended resolution relative to the 1971 AMA/AMPAC Workshop held in Washington, D.C. The amended resolution provides for the ISMS dele- gation to introduce a resolution at the AMA House of Delegates requesting that this meeting be changed to the broad type of public affairs conference conducted an- nually by the Chamber of Commerce of the United States. It further provides that the conference be held in the early part of the week to permit visitation with senators and congressmen in Washington, that the pro- gram be attractive to the general medical society mem- bership and that the program be publicized in advance of the event.
A resolution was adopted directing the ISMS delegates to the AM.A House of Delegates to submit a resolution requesting the formation of a council or committee on public affairs within the AMA structure.
ACTION WITHOUT REFERENCE-COOK COUNTY HOSPITAL
The House adopted a resolution, without reference to committee, recommending the creation of a Committee to be composed of two members appointed by the Gov- ernor, two members appointed by the Mayor of Chicago and a fifth memiter, agreeable to both, who would serve as chairman, to serve impartially in resolving the con- troversies and to seek avenues of agreement between the Hospital Governing Commission and the Cook County Board of Commissioners in order that the Cook County Hospital may remain in full operation.
AD HOC REFERENCE COMMITTEE
A special ad hoc reference committee was appointed to hear medical student views concerning student unrest, campus violence, the war in Indochina and the needs of the medically disadvantaged.
The House agreed with the view's of the Reference Committee in recognizing the mood of helplessne.ss that enveloped the SAMA at the recent convention due to the problems at Kent State, Jackson, Mississippi and in Cam- bodia; that our national priorities need rearrangement and that physicians become involved and accept the chal- lenge to be both healer and citizen.
The House also agreed with the Reference Committee that the free exchange of ideas between members of the Society and the students provided a refreshing segment
of the Annual Meeting, although polarity was present on some of the issues. The House also agreed with the recom- mendation that such an opportunity for student and phy- sician colleagues to have meaningful dialogue of broad issues of concern, be a regular feature of future annual meetings.
In acting upon a resolution submitted on behalf of the students’ viewpoint on the war in southeast Asia, the House adopted a substitute resolution. The substitute resolution provided that the “ISMS exhort the adminis- tration of the United States to continue with all due speed its present policy of intent with respect to humani- tarian principles.”
66
Illinois Medical Journal
VII. REFERENCE COMMITTEE ON EDUCATION & COMMUNITY HEALTH SERVICES
The House reviewed and accepted the reports submit- ted hy the Council on Education and Manpower, the Committee on Scientific Assembly, the Council on En- vironmental and Community Health, Advisory Committee to SAMA, the Cotmcil on Mental Health and Addiction, the Committee on Narcotics and the Committee on Al- coholism.
Commtmications from the Director of the Illinois De- partment of Public Health and the acting Director of the Illinois Department of Mental Health were received as information.
CONTINUING EDUCATION
The report of the Committee on Continuing Education was accepted including two recommendations:
“What Goes On” should be revived, if adecjuate fi- nancing can be obtained; and The Committee on Scientific Assembly should insti- tute refresher courses for credit during the 1971 annual meeting.
Endorsement, in principle, was given to a continuing education program under development by the University of Illinois.
SPEAKERS BUREAU
The House expressed its appreciation of Merck, Sharp and Dohme for continued financial support of the ISMS Scientific Speakers’ Bureau which provides scientific pro- grams for county medical society meetings.
PHYSICIANS' ASSISTANTS
The reports of the new Committee on Allied Health Education were approved. The House gave encourage- ment to the Committee to proceed with its plans to de- velop new categories of physician assistants, including the use of discharged military corpsmen and premedical students unable to find medical school openings. Also the development of an open-ended educational system which would allow assistants eventuallv to become physicians.
The House recommended that more practicing physi- cians be appointed to the Allied Health Committee.
ADMISSION POLICIES OF U OF I
The report of the Student Loan Fund Committee was approved with the recommendation that the llniversity of Illinois be asked to develop admission policies and tutorial services that will give the same consideration to borderline scholars from medically deprived areas as it is now extending to students from the inner city.
LOANS TO OSTEOPATHIC STUDENTS
A resolution was approved endorsing the action of the Student Loan Fund Board to indtide osteopathic stu- dents under the loan program.
LOAN PROGRAM FOR INNER CITY
The House adopted a resolution calling upon the ISMS to appropriate monies from the Task Force on Physician Shortage and Services to Medically Deprived Areas to es- tablish a loan program for the inner city, similar to the present loan program for rural students.
SPECIAL ASSESSMENT
Bv special assessment of $2 per dues paying memher for one year, the Illinois Medical Journal and PULSE are to be mailed to SAM,\ members of Illinois chapters.
NOTE: As an assessment, this amount is not deductible for income tax purposes, as are dues.
LIAISON WITH RESIDENTS AND INTERNS
The .Advisorv Committee to SAMA was instructed to develop and implement a plan of liaison with interns and residents throtigh house staff organization.
NO LEGALIZATION OF MARIJUANA
The House approved the Child Health Committee recommendation that the ISMS oppose any legislation to legalize marijuana. Illinois physicians were encouraged to distribute drug abuse literature through their offices and in schools and be present for discussions, if possible, when drtig abuse films are shown in the community.
WELFARE FOOD ALLOWANCES
In approving the report of the Nutrition Committee, the House adopted six recommendations regarding the IDPA food allowances:
1. The IDPA food allowance should be increased to conform with the USD.\ Low Cost Plan.
2. Every effort should be made to expand and im- plement all supplementary food programs in Illi- nois including the food stamp program, the school lunch program and the supplementary foods program.
3. Food allowances should be adjusted in the fu- ture for increases in the Bureau of Labor Statis- tics Price Index with reevaluations every 3 months and budgeting increases fully commensu- rate with the increase in the costs of living.
4. Other items of the IDPA budget should be re- vised and repriced regularly to make them cur- rent and decrease pressure on the food budget.
5. Consumer education should be further imple- mented and expanded by the most efficient media or method available.
6. Clearing house for nutrition information should be established at a state level with the respon- sibilitv of accumulating and disseminating profes- sional nutrition materials and data.
SHORTER RESIDENCIES
The House endorsed a resohition requesting the .AMA House to condemn Specialty Boards for lengthening train- ing reejuirements and thus removing additional physicians from the practice of medicine.
SCHOOL HEALTH EXAMINATIONS
•A policy was adopted which requires that the ISMS urge all school districts to provide funds in the btidget to em- ploy sufficient doctors and other health professionals to carry out school health procedures as recjuired by law.
NOTE: Present policy on examinations reads as follows:
.All physical examinations should be performed in the physician’s office. No examinations should be conducted on a group basis unless authorization has been given by the local county medical society in a single instance or for a specific purpose.
This general statement does not applv to the industrial or occupational health physician in his in-patient activities,
.An amended resohition was adopted providing that all
for July, 1970
67
physical examinations of children entering kindergarten, lifth and ninth grades may be done within one month of the child’s appropriate birthday, commensurate with the corresponding grade level. The resolution is to be for- tvarded to the State Superintendent of Public Instruction as the basis for altering the Illinois School Code.
PHYSICAL STANDARDS FOR DRIVERS .\n amended resolution was adopted which directs the Committee on Public Safety to prepare a compendium of recommended minimum physical standards for evaluating drivers of specific vehicles, to be submitted at the next annual meeting for approval and subsequent publication.
In further action the House:
Approved the removal of age restrictions on training pro- grams and employment in health occupations under the Illinois State Radiation Protection Act.
Put ISMS on record in favor of state income tax sharing directly with school districts, to completely subsidize school lunch programs.
Adopted a recommendation that the Illinois Health De- ])artment employ a full time constdtant in Ob- stetrics and Gynecology.
Approved the recommendation that sex education be a part of the medical school curriculum.
Rejected a resolution suggesting that young physicians, as :m alternative to military service, be allowed to [nactice in those areas where physician shortages are critical and that equal time, pay and privileges be extended to physicians serv- ing in either the armed forces, or in areas of medical need.
Referred to the Allied Health Education Committee a resolution requesting ISMS to contribute 310,- 000 for 1970-1971 to the Council for Bio-Medi- cal Careers, to develop more interest in health careers among inner city students.
.\dopted an amended resolution asking ISMS to take every appropriate action possible to assist in preventing irreversible health hazards due to the pollution of Lake Michigan.
■\dopted as amended a resolution calling for ISMS to re- cpiest the Dejtartment of HEW to delete a sen- tence from the oral contraceptive package in- sert. which in effect stated that all side effects tvere to be discussed between patient and doc- tor. a policy deemed unwise by the House. Rejected a resolution on increasing the number of medi- cal students in Illinois on the grounds that the Society’s program is already working in this direction.
ACTIONS ON RESOLUTIONS 1970 HOUSE OF DELEGATES
|
Number |
Introduced by: |
|
70M-1 |
Rock Island Co. |
|
70M-2 |
Rock Island Co. |
|
70M-3 |
DuPage County |
|
70M4 |
Madison County |
|
70M-5 |
Madison County |
|
70M-6 |
Madison County |
|
70M-7 |
Madison County |
|
70M-8 |
Madison County |
|
70M-9 |
Madison County |
|
70M-I0 |
Board of Trustees |
|
70M-11 |
Fredric Lake |
|
70M-12 |
.Anna Marcus, for Com. on Medicine &: Religion |
|
70M-13 |
Livingston County |
|
70M-14 |
Livingston County |
|
70M-15 |
Frank J. Jirka, Jr., for Board of Trustees |
|
70M-I6 |
Frank J. Jirka, Jr., for Board of Trustees |
|
70M-17 |
Kane County |
|
70M-18 |
LaSalle County |
|
70M-19 |
Will-Grundy County |
|
70M-20 |
Will-Grundy County |
|
70M-21 |
Will-Grundy County |
Title
Processing of Licensure by Reciprocity Elimination of Reciprocity Examinations
Third party carriers 8c payment of fees Documentation of need for health care in Illinois
Reorganization of PR Program Atidit of Medicare/Medicaid &
IPAC (IDPA)
Promotion of present system of medical care
Audit of Meclicare/Medicaid for info, of the public School health examinations AMA-ERE Llnassigned Funds Affiliate status for III. Chapter .American College of Radiology Seminars on Medicine &: Religion
Elimination of Drug Manual Physical standards for drivers Ad Hoc Status for Comm, on Committees
Permission for AMA delegates to serve on Councils 8c Committees Protection of the Public from Unwarranted medical statements flse of Peer Review mechanism Restriction of occupational exposure of minors School Lunch programs Third Party Claim forms
Action
Adopted
Referred to Medical Legal Council Adopted NOT adopted
NOT adopted
Considered with #8, Substitute Resolution adopted Substitute resolution adopted
Considered with #6, Substitute resolution adopted Adopted as amended Adopted as amended Referred to Board of Trustees Adopted as amended
NOT adopted Adopted as amended Adopted as amended
Adopted
Substitute resolution adopted
NOT adopted Adopted as amended
Adopted NOT adopted
G8
Illinois Medical Journal
|
Number |
Introduced by: |
|
70M-22 |
Will-Grundy County |
|
70M-23 |
Will-Grundy County |
|
70M-24 |
Will-Grundy County |
|
70M-25 |
Will-Grundy County |
|
70M-26 |
Will-Grundy Gounty |
|
70M-27 |
Will-Grundy County |
|
70M-28 |
Will-Grundy County |
|
70M-29 |
W. Plassman, for Com. on Mental Health |
|
70M-30 |
W. Plassman, for Com. on Mental Health |
|
70M-31 |
Lake County |
|
70M-32 |
Lake County |
|
70M-33 |
E. W. Cannady, for AMA Delegation |
|
70M-34 |
J. E. Reisch, for Commission on Physicians’ Liability |
|
70M-35 |
E. K. DuVivier |
|
70M-36 |
Jack Gibbs, for Student Loan Comm. |
|
70M-37 |
Jack Gibbs, for Council on Education |
|
70M-38 |
DuPage County |
|
70M-39 |
DuPage County |
|
70M-40 |
A. J. Faber, for Public Affairs Committee |
|
70M-41 |
J. Ovitz, for Public Affairs Committee |
|
70M-42 |
Fulton County |
|
70M-43 |
Fulton County |
|
70M-44 |
Alfred Klinger |
|
70M-45 |
Alfred Klinger |
|
70M-46 |
4Vinnebago County |
|
70M-47 |
Allison Burdick, for Health Organization to Preserve Environ. |
|
70M-48 |
Will-Grundy |
|
70M-49 |
Herschel Browns |
|
70M-50 |
Board of Trustees |
|
70M-51 |
Chicago Medical Society |
|
70M-52 |
Robert. R. Hartman |
|
70M-53 |
DuPage County |
|
70M-54 |
E. Lowenstein, for 9th District, ISMS |
|
70M-55 |
G. Tomlinson |
Title
Residency training periods Dept, of Public Aid Claim forms— Procedure Long Term Institutional care 111. Medical Society Reserve Funds Powers of House of Delegates under Constitution &: Bylaws Powers of House of Delegates under Constitution & Bylaws Dues Increase
Professional Licensing Policies
Licensing of State Mental Health Facilities Liaison with Hospital Boards Pagination Policy of J.LMA Approval of National Academy of the Health Professions Malpractice
Distribution of AMA-ERF unassigned Funds
Inclusion of Osteopathic Students in Loan Fund Program Opposition to tuition increase at University of Illinois Nursing Service relationships with Medicare
Financial support of County Society Peer Review Committees AMA/AMPAC Workshop in Washington
AMA Physician’s Public Affairs Council
Himler Report— Manpower & Composition of National Academy Himler Report— Resolution of serv. in urban 8c rural areas as alternative to military service
Loan Program for Inner City students §10,000 contribution for Council on Bio-Medical Careers Increased Frequency for Reciprocity Examinations
Pollution of Lake Michigan
Current procedural terminology 8c
relative value study
Cessation of Hostilities in S.E. Asia
Hospital Reimbursement
Med. Services for disadvantaged
& Minority Groups
Oral Contraceptive Pkg. Insert
Countv Society Peer Review Comm.
as 1st appellate body
Increasing number of practicing
physicians in Illinois
Cook County Hospital Controversy.
Action
Adopted
Adopted as amended
Adopted as amended NOT adopted Referred to Board of Trustees Referred to Board of Trustees NOT adopted Referred to Medical- Legal Council Ado]Hed
Adopted
Adopted as amended Substitute resolution adopted
Substitute resolution adopted
NOT adopted Adopted
Adopted as amended NOT adopted Approved in principle Adopted as amended Adopted NOT adopted NOT adopted
Adopted
Referred to Allied Health Education Referred to Medical- Legal Council Adopted as amended
NOT adopted
Substitute resolution adopted Adopted as amended Adopted
Adopted as amended Adopted
NOT adopted
Adopted without referral
for July, 1970
eg
THE VIEW BOX
By Leon Love, M.D.
Director, Department of Radiology, Loyola University Hospital and Chairman, Department of Radiology, Loyola University Stritch School of Medicine
This 60-year-old patient entered the hospital iollowing a sudden occur- rence ot hemiplegia on the lelt side associated with sudden loss ol con- sciousness and an aphasia. The pa- tient was studied arteriographically one week later at which time she was showing evidence of recovery. A left carotid arteriogram was done (Fig. lA, IB, 1C). What’s your diagnosis?
(.4nsw’er on page 92.)
70
Illinois Medical Journal
Evaluation of
Hypnotic effect of Methaqualone
Employing placebo responder elimination
By Arpad Almassy, M.D. /Chicago
Among the problems associated with typi- cal double blind evaluations of hypnotics are the need for large numbers of patients and the often reported lack of discrhnina- tion between doses of soporific drugs com- monly employed in clinical practice and placebo controls. Hinton has reported that 100 mg. doses of butobarbital, quinalbar- bital and amyloharbital were “in most cases insufficient to produce a significant differ- ence from placebo” in the patients studied. Lasagna has suggested, that “placebo reac- tors” may mask real differences between drugs by their failure to discriminate be- tioeen potent and non-potent drugs.
Arpad Almassy, M.D., is on the attending staff at Chicago State Tuberculosis Hospital and Roseland Community Hospital,
Chicago, Illinois. He received his M.D. from the University of Cluj in Hungary, and serv- ed his internship and residency at Cluj. Dr. Almassy was a Board-Certified Internist in Budapest (1948), and received Illinois licen- sure in 1959. He is a member of the American Thoracic Society.
Clinical efficacy of methaqualone, a non- barbiturate hypnotic with an extensive his- tory of clinical usefulness in the manage- ment of insomnia, has been reported by Parsons and Thomson,^ Barcello- and Sa- jrienza.3 In each of these studies, clinical re- sponse to methaqualone was compared with responses to a barbiturate and a placebo. Al- though in each instance these investigators were able to confirm the hypnotic efficacy of methaqualone, they did not find differ- ences between methaqualone and barbitu- rates which might be anticipated on the basis of prior uncontrolled observations, Yaginuma,‘‘ Arvers,® and Ravina.®
Since Lasagna'^ has indicated that respon- siveness to placebo may decrease sensitivity of clinical studies and thus obscure real dif- ferences between drugs, we attempted to de- vise a means by which the incidence of jrlacebo reactors might be reduced.® This procedure, previously reported, was em- ployed in conjunction with a clinical com- parison of methaqualone,* pentobarbital and placebo in patients suffering from in- somnia.
*SOPOR®, Arnar-Stone Laboratories, Inc.
tor July, 1970
73
Materials and Methods
Forty-eight male j^atients, who had been hospitalized for the treatment of chronic respiratory disorders, were selected for study. The age range was from 27 to 87 years. Debilitated patients, as well as those with severe disorders of liver or kidney function, were excluded. Similarly, patients who described only moderate difficulty in getting to sleep and only occasional periods of wakeftdness dtiring the night were not included.
Only patients with moderate insomnia (sleeplessness every night with difficulty in getting to sleep, and two or three periods of wakefulness every night) and severe in- somnia (defined as an inability to obtain a satisfactory night’s sleep without the use of hypnotics) were selected for study.
In 13 patients the history of insomnia Ite- gan with the date of hospitalization. In the entire series the history of insomnia ranged in duration from several clays to several years. Only 15 patients had never received hypnotic medications in the past. Barbitu- rates had been most commonly employed (23 patients).
During the first phase (Phase I) of the ])iesent study, in an attempt to eliminate the placebo reactors, all 48 patients re- ceived a placebo capsule (SUIds,® Arnar- Stone Lalioratories), containing sucrose and cornstarch, at bedtime. Phase 1 was not double-blind, and the patients were told that the capsules were intended to help them sleep. The placebo capsule j^roduced a satisfactory response, which was sustained for a period of 14 days, in 13 patients. I’hese patients were classified as placebo reactors and drojjped from the study group. Eight others were also eliminated from the study, for a variety of reason.s, i.e., refused to accept medication, during Phase I. The remaining 27 patients, who had not shown an adequate or persistent responsiveness to the placebo capsule, were then transferred to the second phase (Phase II) of the study.
For the second, double-blind, phase of the study all medications were dispensed as compressed yellow tablets containing 150 mg. of methaqualone, 100 mg. of pento- barbital sodium, or inert ingredients. The assignment of patients was by means of a series of random numbers, and medications were dispensed by personnel not involved in the evaluation of the response. Thus,
neither the patient nor the physician knew the identity of the drug used in a given patient. At the conclusion of Phase II, it was fotincl that ten patients had been re- ceiving methat|ualone, nine patients had been on pentobarbital sodium, and eight had been receiving the placebo (as they had dtiring Phase I).
Results
The overall response to therapy was evaluated each morning for each patient, d'he criteria included ease of falling asleeji, frec[uency of awakening during the night, and the presence or absence of “hangover” or other side effects. All data were collected
Table 1.
The Overall Response to Therapy No. of
|
Drug |
No. of Patients |
Nights Evaluated Excellent |
Good |
Fair |
Poo |
||
|
Phase |
I* |
13 |
162 |
56 |
92 |
13 |
1 I |
|
Phase |
II Methaqualone |
10 |
123 |
35 |
73 |
13 |
2, |
|
Pentobarbital |
9 |
96 |
26 |
36 |
14 |
20 |
|
|
Placebo |
8 |
78 |
12 |
37 |
22 |
7 |
|
|
* Single-blind |
phase— placebo |
reactors. |
daily by the ward physician personally, and correlated with the nurses’ notes. An addi- tional parameter, based on an objective evaluation of the duration of sleep was also measured, as described below. This evalua- tion yielded the following results:
It shotdd be emphasized that the 13 Phase I patients were “placebo responders” who were not subsecjuently transferred to the double-blind second phase. The per- centage of patients showing an excellent response on methaqualone and pentobarbi- tal (28% and 27% respectively) was essen- tially identical and approximately twice as great as that on the jffacebo (15%). A dif- ference between methaqualone and pento- haibital became more evident when the percentage of excellent and good responses were combined. Thus, the percentage of excellent-good responses on methacpialone was 88; compared with 65 on pentobarbital, and 62 on the placebo. It should also be noted that the percentage of poor responses was greatest in patients receiving pento- barbital.
In addition to the cjualitative assessment of the response summarized above, an ob- jective semi-quantitative evaluation based on the duration of sleep was also performed. The elapsed time between the onset of
74
Illinois Medical Journal
Average Adjusted Sleep Scores (Hours)
Figure 1.
Phase I Placebo Responders |
Phase I Placebo Non-Responders |||||||| Phase 11 Methaqualone Phase 11 Pentobarbital Phase II Placebo
sleep and time of awakening was adjusted by subtraction of the duration of periods of wakefulness during the night. If a jjeriod of wakefulness was less than 30 minutes, or if the duration could not be determined, 30 minutes was arbitrarily subtracted (Za- roslinski, et al).®
During Phase 1 (in the 13 placebo re- sponders) the average adjusted sleep score was 6.9 ± 0.15 hours. In those patients who were not responsive to the placebo in Phase I (the 27 patients subsequently transferred to Phase II), the average ad- justed sleep score was 3.7 ± 0.19 hours. During Phase II the adjusted sleep score on methaqualone was 7.0 ± 0.28 hours; on pentobarbital it was 6.2 ± 0.45 hours; and on the placebo it was 4.8 ± 0.78 hours. These average adjusted sleep scores may be compared graphically as in Figure 1.
The average adjusted sleep scores for methaqualone, pentobarbital, and placebo were compared using Fisher’s Analysis of Variance Techniques (Batson).** Prelimin- ary analysis of variance clearly established that the scores differed significantly (P<0.01). The alternate analysis of vari- ance test was then enqaloyed to determine differences between the individual groups. Examination of the residt data showed that methaqualone was significantly more effective (P<0.05) than both pentobarbital and placebo.
The response to methaqualone was sig- nificantly superior to that induced by pen- tobarbital or placebo. There were no serious side effects reported for any of the medications during the course of this study. Occasional patients complained of minor effects such as drowsiness, etc., but were too few in number to permit a mean- ingful statistical analysis.
Discussion
Selection of patients for a clinical study usually presents problems in regard to the suitability of particular subjects. Ostensibly, careful observation and case history should serve to facilitate such selection. However, our results suggest that full reliance on these ])rocedures may result in the inclu- sion of some subjects who are not fully suitable as clinical material. Pre-screening with respect to placebo responsiveness would appear to be worthwhile.
It is of interest that the response to metluupialone was significantly superior to that of pentobarbital both qualitatively and (piantitatively. This is in contrast to results rejjorted by Parsons,' Barcello,^ and Sa- pienza.® These authors found no significant difference between effects obtained with metluupialone and cyclobarbital, secobarbi- tal, and pentobarbital, respectively. The subjective excellent-good-poor grading of patient response has been widely employed by clinical investigation and may be re- sponsible for failure to exhibit differences between hypnotics, or hypnotics and place- bo, in the usual clinical dosages. Objective data is preferable, and the patient’s response should be the valid goal of such a study. We believe that the addition of the semi- quantitative evaluation introduced here en- hances the validity of the study and in- creases the degree of discrimination.
The preliminary elimination of placebo responders, 32.5% of the population, may account for this difference. The omission of placebo responders appeared to make the population being tested more homogeneous and decrease extraneous variables. Deletion of placebo responders appeared to increase the sensitivity of the clinical test procedure
for July, 1970
75
by providing a more valid insomnia popu- lation. Thus, the drug response is being tested against the specific complaint and the hnal results are not being diluted by patients which normally respond to placebo therapy. However, insomnia is self-limiting and a degree of placebo response can occur even after preliminary elimination of de- finite placebo responders.
The importance of the “placebo reactor” in the evaluation of drugs has been describ- ed by Lasagna," Batterman^oii and Zaros- linski, et al.® Since there is an important psychosomatic element in insomnia, com- parisons of hypnotic drugs should include elements designed to reduce the impact of the placebo responder insofar as this is pos- sible. We believe that this was largely ac- complished in the present study by its di- vision into phases, the first of which was solely designed to eliminate placebo re- sponders.
Because of the additional control ele- ment provided by the first phase of our study, it is our opinion that the validity of our results is enhanced and a more accu- rate determination is possible with fewer patients. These results indicate that a dose of 150 mg., methaqualone is a highly effec- tive hypnotic. Methaqualone was found to produce a statistically significant increase in the adjusted average duration of sleep when compared to pentobarbital and place- bo. This value of the duration of sleep was valid both qualitatively and quantitatively.
Summary
Forty-eight male patients, who had been hospitalized with various chronic respira- tory diseases, were selected for a double- blind, placebo-controlled evaluation of methacpialone and pentobarbital sodium in the management of insomnia. The study was divided into two phases. During the first phase, all patients were given a pellet- containing, placebo capsule. During this phase, which was not double-blind, eight patients were dropped from the study group for various reasons. Twenty-seven others were taken off the placebo within 14 days because it failed to induce a persistently
adequate response. These patients subse- quently entered the second phase of the study. Finally, there were 13 patients who responded consistently to the placebo, and when this responsiveness was found to con- tinue for a period of 14 days, they were removed from further consideration as “placebo reactors.”
During the second phase of the study, ten patients received methaqualone (150 mg. at bedtime), nine were given pento- barbital sodium (100 mg. at bedtime), and eight received the placebo. Both medica- tions and the placebo were in the form of compressed, yellow tablets, and this phase of the study was double-blind. In addition to subjective observation recorded by train- ed medical observers, a semi-quantitative parameter of adjusted sleep duration was evaluated.
The percentage of excellent and good re- sponses on methaqualone (88) was greater than that on pentobarbital (65) or placebo (62). The adjusted average duration of sleep on methaqualone (7.0 hours) was greater than that of pentobarbital and placebo to a statistically significant degree.
References
1. Parsons, T. W., and Thomson, T, J. “Metha- qualone as a Hypnotic,” Brit. M. J., 1:171-173 n961).
2. Barcello. R, “A Clinical Study of Methaqua- lone: A New Non-Barbiturate Hypnotic,”
Canad. M. A. J., 85:1304-130,5 (1961).
3. Sapienza, P, L. “A Double-Blind Comparison of Methaqualone, Pentobarbital and Placebo in the Management of Insomnia,” Cnrr. Therap. Res., 8:523-527 (1966),
4. Yaginuma, Y,, Gonoi, T. and Kokubus, S. Brain Nerve (Japan), 13, p. 469 11961).
5. Arvers, J. J., These Med., Paris (1958).
6. Ravina, A., Press. Med., 67:891-892 (1959).
7. I.asagna, L., Mosteller. F., Von Felsinger, J. M., and Beecher, H. K. “A Study of the Placebo Response,” Am. J. Med., 16:770-779 (1954).
8. Zaroslinski, J. F., Browne, R. K., and Almassy, .\. "Placebo Response in the Evaluation of Hypnotic Drugs,” J. Clin. Pharmacol. (1969).
9. Batson, H. C. An Introduction to Statistics IN THE Medical Sciences. Burgess Publishing Co., Minneapolis, Minn., 22-37 (1961).
10. Batterman, R. “Persistence of Responsiveness with Placebo Therapy Following an Effective Drug Trial,” J. New Drugs, 6:137-141 (1966).
11. Batterman, R., and Mouratoff, G. “Reproduc- ibility of Data: Test of Method for Evaluat- ing Sedative and Analgesic Medications,” Cnrr. Therap. Res., 5:444-449 (1963).
Little Facts About Big Government
The U. S. Department of Agriculture spent five years revising pickle standards in order to describe the difference between curved and crooked pickles.
76
Illinois Medical Journal
SOCIO ECONOMIC
news
A service of the Public Relations and Economics Division
''Foundations for Medical Care" Considered
Black Ink "A Must" On Vital Records
ISMS Members Support Public Health Programs
By Joseph J. Lotharius
ISMS Trustees are seriously considering the pros and cons of the “Foundation for Medical Care” concept. FMC’s are presently active in several California counties and their popularity is beginning to spread eastward. An FMC is an organization of physicians, sponsored by a local medical society, who are concerned with the development and de- livery of medical services and the reasonable cost of health care, rvhether privately or publicly financed.
The FMC concept includes free choice of a personal physician, the fee for service concept, and local control through peer review mechanisms. FMC’s can set up mini- mum health care standards and offer broad coverage with- in a reasonable cost level. Quality care is emphasized through utilization review techniques by both physician and patient. Is the FMC concept the “wave of the future” — ancl the answer to a national health insurance system?
All Illinois physicians, funeral directors, coroners and hospital administrators were urged to start using black ink when filling out vital records which will be reproduced. The request was made by Dr. Franklin D. Yoder, director of the Illinois Department of Public Health. Dr. Yoder announced that beginning January 1, 1971, his Depart- ment would instruct local registrars and county clerks to accept for filing ONLY those certificates filled out in black ink. He said in order to insure clear, sharp certified copies from either a photocopy or from microfilm, the original certificate must be prepared in clean, black typewriter rib- bon or black ink.
A recent ISAIS survey of county medical societies revealed nearly 2,500 physicians gave more than 12,500 free man- hours of time worth an estimated .|I660,000 to public health programs during the past year. Over 800,000 children benefited from free inoculations or screening programs during the 12-month period ending May 15. Inoculation programs included rubella, measles, diphtheria, smallpox and polio. Screening projects included pre-school visual exams, hearing and vision tests, physical examinations, tu- berculosis and diabetes testing. These statistics are very conservative because less than 25 per cent of the state's county societies responded to the survey.
for July, 1970
81
Be EXACT On Your Medicare Claim Form
RE: Third Parties And Fees
Physicians treating Medicare patients should make cer- tain their patient’s name listed on the 1490 claim form is an EXACT duplicate of the name appearing on the pa- tient’s health insurance card. According to Continental Casualty Co., Part B Medicare carrier for much of Illinois, any difference, however slight, could delay your claim as much as 90 days. Continental reported that all Medicare eligibility records are maintained in Baltimore by the So- cial Security Administration and computerized techniques in checking records require the exact information.
•I‘**I**I**I"*I'**I**I**I''*l''*I''*I’'*i**I""I"*I""I**I""I*
ISMS Delegates reaffirmed three basic principles during the convention regarding third party carriers and payment of fees. These are: 1) Unless a physician accepts assignment as payment in full, the patient, not the third-party, is re- sponsible for payment of medical fees; 2) a patient should be reimbursed by his insurance carrier for necessary consul- tation fees; and 3) a physician’s usual and customary fees should be accepted as such by the carrier, with contractual reimbursement made to the patient, with the carrier implying any “overcharge.”
Film Reviews
The nature of cystic fibrosis, its genetic transmission, procedures for diagnosis and treatment are explored in “Diagnosis and Management of Cystic Fibrosis," a 16mm, sound, color film. The film refers to research attempting to establish the etiology of cys- tic fibrosis and to pinpoint the underlying biochemical defect v/hich results in the se- cretion of abnormal sweat, saliva, and mucus. Also discussed in the film are diet, exercise, the role of the parents in home care, surgical complications and child-bear- ing by young women affected with the dis- ease. Contact for free short-term loan; Na- tional Medical Audiovisual Center (Annex), Station K, Atlanta, Georgia 30324, Attn: Film Distribution.
"A Matter of Opportunity," a 16mm, 27 minute film explores the situations faced by black students as they pursue careers in the field of medicine. The need for black phy- sicians, black paramedical people, black midwives, and black nurses is also dis- cussed in the film, available on loan to medical societies from the AMA Film Li- brary, 535 North Dearborn Street, Chicago 60610.
"Intestinal Amebiasis" and "Extraintes- tinal Amebiasis" are two of the 16mm films in the clinical pathology series. Illustrations include drawings and photographs of the parasite, typical and atypical ulcers, and preparation of wet mounts. The aspects of extraintestinal amebiasis, including hepa- tic abscess and cutaneous complications are dealt with in the second film. Contact for free short-term loan: National Medical Au- diovisual Center (Annex), Station K, At- lanta, Georgia 30324.
"Current Trends in the Therapy for Nar- cotic Addiction," a 16mm, 29 minute film features Dr. Daniel H. Casriel, medical psy- chiatric superintendent of Daytop Village, a therapeutic community for addicts, and Dr. Jerome H. Jaffe, director of the Drug Abuse Program in Illinois. Dr. Casriel views narcotic addiction as "withdrawal behind a chemical as a response to stress." Dr. Jaffe questions the psychiatric approach and dis- cusses the methadone treatment of addicts in Chicago. Contact: National Medical Au- diovisual Center (Annex), Station K, Atlan- ta, Georgia 30324, for free, short-term loan.