inThe Journal Research Articles

Types of pacemakers.

To the Editor:— Two different types of pacemakers have been built that avoid competition between the electrical impulse and idiocardiac contractions. One of these is the standby pacemaker (of which there are two models). We had the privilege of publishing our first experience with this pacemaker inThe Journal, and subsequently elaborated on this experience elsewhere.1-3At the same time others developed a pacemaker.4 The article by Goetz (205:657, 1968) as well as your editorial, Apace With Pacemakers, continued to refer to demand pacemakers without reference to standby pacemakers, as if the two were somehow different and unrelated. Despite the slight difference in mode of operation of standby and units, the distinction between them is largely semantic. In both cases a spontaneous idioventricular contraction will affect the next scheduled pacemaker impulse to prevent the implanted pacemaker from firing a stimulus into the vulnerable period of

Thromboembolic Disease And Oral Contraceptives

<h3>To the Editor:—</h3> Drill and Calhoun's article inThe Journal(<b>206</b>:77, 1968) concludes that contraceptives do not increase the incidence or recurrence of thromboembolism in nonpregnant women of childbearing age. The statistical approach of the authors is not in agreement with studies of a small but well-controlled number of patients whose clotting mechanism was studied before and after they were placed on the pill (Egeberg and Owren,<i>Brit Med J</i><b>1</b>:220, 1963). Coagulation factors V, VI, and VIII increase so as to produce a hypercoagulable state, as reported several times. It can also be shown, just as in the last trimester of pregnancy (Nielsson, J.M.,<i>Acta Obstet Gynec Scand</i><b>46</b>:286, 1967), that the fibrinolytic mechanism of the individual on contraceptives is impaired. These studies are far more in accord with clinical experience and with the two British studies which the authors discount. Mass statistics of thromboembolic disease

Diarrhea Associated With Thyroid Medication

To the Editor:— Dr. William B. Parsons, Jr., gave a concise and scholarly answer to the question posed inThe Journal( 204 :185, 1968). This had to do with causes of diarrhea associated with thyroid medication. Another possibility to explain the persistence of diarrhea which is related to the medication and which appears to be relatively new was not mentioned. This is that thyroid preparations and other similar animal products used in human medicine have been found contaminated with various species of Salmonella . It was not stated whether this patient, with the diarrhea, had bacteriological examinations of stools. Findings of Salmonella contamination in commercially available food and drug products including hormonal and enzymatic preparations used in medicine indicate a continuing need for bacteriologic studies of stools in cases of diarrhea.

Intraaortic Balloon Pumping

To the Editor:— With reference to our article, Initial Clinical Experience With Intraaortic Balloon Pumping in Cardiogenic Shock, which appeared inThe Journal(203:113, 1968), at the time our addendum regarding three additional patients was submitted, a complete follow-up on the sixth patient was not available. The patient subsequently died seven days after the procedure, from pulmonary complications. His hemodynamic status remained stable until his sudden death from pulmonary and renal complications.

The Reporting of Venereal Disease

To the Editor:— I am deeply disturbed by the article and the editorial concerning the reporting of venereal disease inThe Journal( 202 :941, 1967). Cleere and associates begin by establishing that reporting is required by law in each of the 50 states of America. They proceed to cite data which indicate there is considerable noncompliance with these laws, and conclude that most physicians comply some of the time. They then suggest this is due to lack of information, understanding and trust. The recommended solution is for public health workers to provide information about the reasons for reporting and demonstrations of trustworthiness. The point that disturbs me is that both the article and the editorial suggest that physicians should be allowed to decide when and under what circumstances they will comply with a law which requires reporting of venereal disease. If this is accepted, to what extent can the principle

Institutional Differences in Postoperative Death Rates

The National Halothane Study was designed to examine the possible association of halothane anesthesia and postoperative massive hepatic necrosis. It was a retrospective survey of the incidence of fatal massive hepatic necrosis and overall death rate following general anesthesia in 34 hospitals for the four-year period from 1959 through 1962. A summary of the observed incidences of liver necrosis and mortality following halothane anesthesia and following use of other general anesthetic agents has been published inThe Journal. 1 One important by-product of the study was the finding of large differences in postoperative mortality occurring among the participating institutions. The following communication represents a summary of the statistical analysis of these institutional differences and a discussion of their possible significance. Death rates for the six-week period following surgery varied widely among the 34 institutions cooperating in this study. These death rates ranged from 0.27% to 6.40%, a 24-fold ratio. In

Institutional differences in Postoperative death rates. Commentary on some of the findings of the National Halothane Study

The National Halothane Study was designed to examine the possible association of halothane anesthesia and postoperative massive hepatic necrosis. It was a retrospective survey of the incidence of fatal massive hepatic necrosis and overall death rate following general anesthesia in 34 hospitals for the four-year period from 1959 through 1962. A summary of the observed incidences of liver necrosis and mortality following halothane anesthesia and following use of other general anesthetic agents has been published inThe Journal.¹One important by-product of the study was the finding of large differences in postoperative mortality occurring among the participating institutions. The following communication represents a summary of the statistical analysis of these institutional differences and a discussion of their possible significance. Death rates for the six-week period following surgery varied widely among the 34 institutions cooperating in this study. These death rates ranged from 0.27% to 6.40%, a 24-fold ratio. In

Accuracy of Laboratory Diagnostic Services

To the Editor:— A recent article inThe Journal( 202 , Oct 16, 1967, adv p 46), entitled House Approves Laboratory Licensing Provisions, contained the statement, He contended one out of every four diagnostic tests may be inaccurate. A statement of this nature was made by Dr. David Sencer, Director of the National Communicable Disease Center, before a hearing of the Senate Antitrust Subcommittee. Although the statement has received great public exposure, it leaves much to be desired in the realm of factuality. The basis for Dr. Sencer's statement was data obtained by NCDC surveys of 67 federal laboratories (ie, marine hospitals, outpatient clinics on Indian reservations, etc). These surveys included determinations of values for hemoglobin (November 1964) and serum electrolytes (October 1965 to May 1966). There was no participation in these surveys by nongovernmental hospitals or independent laboratories of any kind, and the reports are not remotely representative of countrywide

Mesothelioma Associated With Asbestosis

To the Editor:— May I comment on the excellent paper by Maxwell Borow et al which appeared inThe Journal( 201 :587, 1967)? On page 591 they quote me as stating that I produced experimental mesotheliomas with three types of asbestos, and also with silica. This appeared in the preliminary paper ( Nature 196 :180,1962). Further experiments were undertaken which were mentioned in New York ( Ann NY Acad Sci 132 :505, and not 77-86, as quoted by the authors of the paper). In this paper I explained that we had confirmed the previous results with the three types of asbestos, but were doubtful if the silica tumors were in fact mesotheliomas. In a further paper given at Perugia 1 I described the silica tumors in detail and concluded that they were not mesotheliomas, but definitely reticulum cell sarcomata. This view has since been confirmed by Dr. A. H. T. Robb-Smith.

Large Intravenous Dosage of Thiamine

<h3>To the Editor:—</h3> I have read with considerable interest Dr. Haunz's answer to "MD, Florida" [<b>201</b>:901, 1967] but am rather concerned that large intravenous doses of thiamine hydrochloride, ie, 100 mg daily for seven days, are recommended. Doses of this vitamin<i>given on its own</i>are liable to induce anaphylactoid reactions, and there are at least six fatal cases published in the world literature. However, from experience in the United Kingdom, when such large doses of thiamine hydrochloride are given intravenously<i>with other members of the B complex</i>(eg, in the treatment of certain psychiatric emergencies) the risk of such reactions is negligible. I would agree with your contributor that prolonged thiamine deficiency could be a possible reason for apparent carbohydrate dyspepsia, but I would like to suggest, with respect, that estimation of erythrocyte transketolase activity inThe Journal(<b>187</b>:762, 1967) is a more specific indicator of thiamine

The Sentinel Pile and Brodie

To the Editor:— May I take this opportunity to compliment the editors ofThe Journalon publishing biographical sketches of outstanding persons who have made significant contributions to the progress of medicine. InThe Journal( 200 :331, 1967) an excellent biographical flashback of the great London surgeon, Sir Benjamin Collins Brodie, stated that he recognized the significance of the sentinel pile at the lower end of the fissure. However, Sir Benjamin Collins Brodie has not left a written description which in any way resembles the sentinel pile referred to by some of our present day writers. His lectures on anorectal diseases delivered at St. George's Hospital and published in the London Medical Gazette do not mention, by identification or description, a sentinel pile. Moreover, his clinical remarks on ulcers of the rectum delivered at St. George's Hospital and published in the London Medical and Surgical Journal mention no tissue to

Photosensitivity to Cyclamate

To the Editor:— When a report of a single reaction to a commonly used substance is given a prominent place inThe Journal, it seems to me that this constitutes a disservice to medicine. This has been done with the report of a single photosensitivity reaction to calcium cyclamate in the article by Lamberg ( 201 :747, 1967). Such a report should properly appear in the CLINICAL NOTE section, not among the featured articles. The article, which is a fine one, includes a complete workup on one patient with a reference to a few other patients, seven of them in Japan, and the important reminder that we should remember that cyclamate can cause photosensitivity reactions. This is certainly well worth learning. However, the prominence given inThe Journalto this particular article, combined with the frequent reminders from the Food and Drug Administration concerning reactions to medications of all types, adds

Signs of Impairment of The Sciatic Nerve

To the Editor:— The comments by Dr. Whitehill inThe Journal(201:641, 1967) are quite pertinent and important. When one does the toe-rise test on each foot as he describes, not only is the weakness that he is demonstrating produced by sciatica, but the inability to do a single toe-rise can indicate loss of balance due to weakness in any component in the leg or supporting muscles from the hips down. It does not imply compression of the nerve by hyperextension and tension on the nerve so much as weakness. One might add that a second valuable sign of sciatic neuritis, or any form of weakness in the leg, is to compress the knee towards the ground while the patient is sitting, therefore, measuring the strength of hip flexion. Invariably, hip flexion and abduction weakness develops in unilateral sciatica, or for that matter, any type of seemingly distant, unrelated

Short-Term Psychiatric Treatment

<h3>To the Editor:—</h3> In his letter "Psychiatrists as Physicians" inThe Journal(<b>201</b>:334, 1967), Earle M. Chapman calls for professional courtesy by psychiatrists, stating, "Modern psychiatric treatment is short term...." Modern psychiatric treatment is not short term in many instances. Often when it is short term, it is not because that is the treatment of choice, but because of the pressure of numbers in public clinics and financial pressure in the private setting. Doctors and their families are usually able to afford long-term psychiatric treatment which others may need, but cannot afford. Short-term psychiatric treatment is indicated in certain situations, some acute depressions, family or individual crises, some marital problems, etc, and often makes a profound difference in the outcome. Drugs are indicated to relieve symptoms in certain neuroses and are a primary treatment in most cases of schizophrenic reactions and severe depressions. However, neurotic, psychophysiologic, and less malignant

Successful Cardiac Massage, Open and Closed

To the Editor:— Shocket and Rosenblum present a most provocative account of successful open cardiac massage following unsuccessful closed-chest cardiopulmonary resuscitation inThe Journal( 200 : 333, 1967). They reported that 75 minutes of closed-chest massage sustained but failed to resuscitate a 32-year-old patient. This report among others demonstrates the need for high standards in closed-chest cardiopulmonary resuscitation. The authors report a common cause of failure in closed-chest cardiopulmonary resuscitation, that of inadequate attention to detail. Success requires prompt and adequately performed emergency measures ( for sustaining life ) and specific therapy for resuscitation, per se. The National Research Council has approved the high standards of both emergency and definitive therapy outlined by the American Heart Association's Committee on Closed-Chest Cardiopulmonary Resuscitation ( 198 :372, 1966). Repeated administration of epinephrine at intervals of five minutes is strikingly effective in increasing perfusion pressure and, more importantly, the vigor of ventricular fibrillatory activity. The latter is

The Treatment of Hyperthyroidism

To the Editor:— The editorial inThe Journal( 200 :162, 1967) entitled Treatment of Hyperthyroidism displays a regrettable lack of objectivity. All present methods of treatment for hyperthyroidism possess certain disadvantages, and the cumulative long-term incidence of hypothyroidism after treatment with radioactive iodine is certainly among them. However, the magnitude of this disadvantage is moot. Total thyroid ablation by radiation or surgery has long been employed in the treatment of certain cardiac disorders, rarely in severe diabetes and blood dyscrasias, and more recently in progressive ophthalmopathy complicating Graves' disease. Accidental post-therapeutic myxedema is amenable to complete control by adequate doses of thyroid hormone, the principal risks appearing consequent to the patient's lapse from supervision and treatment. While emphasizing the 70% estimated cumulative incidence of hypothyroidism ten years after radioactive iodine treatment, cited by Nofal et al, the editorial fails to mention other data in the same article. These include the

Torsion of the Spermatic Cord

To the Editor:— I was extremely interested in the two articles in reference to torsion of the spermatic cord ( 200 :669, 673, 1967). I think this would make an excellent subject for an editorial inThe Journal. This is an extremely important problem—one that has not been emphasized by the medical schools. It is not a rare abnormality. I am associated with three other urologists, and we will see a torsion of the spermatic cord at least once every four to six weeks. In fact, we recently operated on one that was some 10 days old; the testicle, of course, was completely infarcted. We operated on the opposite side and did an orchipexy to prevent a torsion from occurring on the uninvolved side. I have seen two cases in which torsion later occurred on the uninvolved side, and the testicles in both cases were completely destroyed. A physician should consider

Intravenous Use of Diphenylhydantoin Sodium

<h3>To the Editor:—</h3> Two fatalities have been reported inThe Journal(<b>200</b>:335, 1967) in association with intravenous administration of diphenylhydantoin (Dilantin) sodium for the treatment of cardiac arrythmias. Amounts administered were 250 mg and were reported as being given over a period of two to three minutes. We have used diphenylhydantoin sodium intravenously to treat status epilepticus in 36 patients and cardiac arrythmias in 75 patients. It was effective in stopping seizures in about half of the patients. It was also predictably effective in abolishing premature ventricular contractions, but it did not usually correct sino-auricular arrythmias. The dose given ranged from 500 to 1,000 mg administered at a rate of not over 100 mg/min, and usually the rate of administration was less, 10 to 50 mg/min. Of the 111 patients treated, 105 have shown little or no changes of blood pressure and respirations. In one patient who received 1,000

Safety Levels of Oxygen Flows

To the Editor:— In a recent editorial on the dangers of administering high concentrations of oxygen ( 199 : 494, 1967), no mention was made that low flow rates of oxygen are not only lifesaving, but safe. Too many deaths occur because oxygen is withheld from severely ill patients with pulmonary emphysema. Cherniak and Hakimpour recently presented inThe Journal( 199 : 178, 1967) their studies revealing the safety of low flow rates of oxygen. At the same time, Cullen had a similar paper in the American Review of Respiratory Disease ( 95 : 116, 1967). Simpson in England specifically states that since he has used low flow rates of oxygen with a graded increase in the oxygen concentration, he has not encountered ill effects. I have employed this procedure since 1938 and have never seen coma or adverse effects from its use. Naturally, it is disturbing to see reference to one side of a

Drug Identification: Use of Coded Imprint

WHETHER involved in a child's accidental ingestion or in an adult's suicide attempt—or, for that matter, simply as the focus of an about-to-expire prescription—the unknown medication presents an enigma. Be it the blatantly unrecognizable, anonymous small white tablet or the multi-colored, characteristically coated capsule pleading for recognition, the unknown medication all too often defies precise identification, or occupies far too much time in achieving it. Various techniques have been advocated to overcome this obstacle. Proposals range from the naivete of clearly signifying generic names on prescriptions, so the patients will learn and remember them, to the equally ineffective suggestion of labeling all drug containers—from which medications are so frequently transferred to other containers. At a far more realistic conceptual level, Heffernen contrived his monumental Identification Guide for Solid Dosage Forms . With specificity based on contrasts in physical characteristics, ie, shape, size, color, etc, the code was published inThe Journal