inThe Journal Research Articles

Loaded Language And Drug Use

To the Editor.— I agree with the main points presented inThe Journal'seditorial (226:660,1973). However, the authors made an error of their own in interpretation of addict terms used in scientific journals. In my three years of experience with the addict and as a director of a methadone maintenance program, skin popping is not injecting intradermally, but is the subcutaneous or intramuscular injection of a compound—usually heroin—and usually into the deltoid or buttock area. Intradermal injection of street with its various diluents would certainly cause necrosis of the dermis in many instances. Skin popping is normally done at two different stages of opiate use; either at the beginning, when the technique of intravenous injection has not been mastered and the heroin rush is not desired, or after the person (usually a long-time addict) has destroyed all of his veins, and skin popping is the only available route

Improving the Image of the Physician

To the Editor.— It is seldom that I take time to read all of the letters in any medical journal, but the one by Dr. Rosenberg inThe Journal(226:565, 1973) caught my eye. I could not more heartily agree with the points raised by Dr. Rosenberg, but I feel that it is a sad indictment of present medicine that it is necessary to publish such a letter. I feel that his views should be more widely disseminated among the physicians of this country with a view toward increased understanding of the dangers both to individual physicians and to medicine in general incurred by careless remarks, inadvertent deprecation of other physicians' efforts, or just plain unwarranted criticism. I trust that you might find it proper to see that these views are disseminated more widely with a view toward improving the image of medicine in the public's eye and perhaps in

Letter: The Tenckhoff catheter for peritoneal dialysis.

To the Editor.— Rae and Pendray inThe Journal(225:937,1973) have recommended peritoneal dialysis with the silicone-rubber tube described by Tenckhoff and Schechter for permanent and temporary treatment of chronic renal failure. In our clinic, 82 Tenckhoff catheters were implanted in 65 patients during 33 months, with 2,146 peritoneal dialyses within 262 cumulative months. Clinical signs of peritonitis were observed in 21 patients; in ten of these treatment was effective and the catheter remained unimpaired. The other 11 had to be removed. In three cases fibrin clots obliterated the catheter lumen, in three others there was an infection of the skin tunnel, once a loosening of the catheter and once its penetration into the intestinal lumen occurred. During the present observation time the average survival time was just over three months, but in a few cases the catheter lasted for more than one year. The survival time was mainly limited

The Sickle Cell Trait

To the Editor.— The editorial on the pathogenic effects of the sickle cell trait, signed by Heller (225:987, 1973) has more historical background than appears on the surface. Beginning with my editorial, Mass Screening Programs for Sickle Cell Hemoglobin, inThe Journal(221:500, 1972), some polemics have appeared, including Dr. Heller's letter (222:360, 1972). He categorized the use of the term AS disease as a disservice to the two million black Americans who are heterozygous for hemoglobin S, speaking rather pointedly of uncritical authors who rush to the occasion and write articles about events that could be chance phenomena. Yet even Heller in his editorial admits that trait victims may sustain splenic infarcts, hematuria, hyposthenuria, and factors... cause sickling, tissue damage due to ischemia, and clinical disease. He did not mention that some refractory cases of hematuria require nephrectomy. Nor did he note that there are well over 150 articles

Letter: Salivary levels and digitalis toxicity.

To the Editor.— I have read with interest the EDITORIAL by Dr. Samuel Vaisrub, Salivary Electrolytes and Digitalis Toxicity, which appeared inThe Journal(225:519, 1973). I do not agree that there is impressive evidence that salivary electrolytes will reveal digitalis toxicity when not shown by an electrocardiogram or serum levels. On the contrary, the lack of correlation between serum levels and salivary electrolytes shown in all of the references mentioned 1-3 tends to make me disregard salivary electrolyte determinations as a meaningful evaluation in the assessment of digitalis toxicity. Virtually all of those 4-6 who have studied the correlation of digitalis serum levels with toxicity, except Fogelman et al, 7 find a high degree of statistical correlation. The major shortcoming of serum level determinations obtained by radioimmunoassay is the overlap between patients normally digitalized, as well as underdigitalized, and those with toxicity. In brief, the radioimmunoassay for digitalis in

Another Counter-Blaste

To Editor.— A recent note inThe Journal(220:1172, 1972) compares the right to be free from smoke with the right to smoke. I have two further comments. Cigar and Pipe Smoking and Cancer.— As early as 1955, Ochsner wrote: Prominent cancer investigators sobered by their own findings, have switched from cigarettes to pipes or cigars to reduce risk of lung carcinomas,1 but actually, smokers who have switched from cigarettes to cigars and pipes to avoid cancer of lung do not avoid risk of cancer. An association between smoking and cancer was recognized long before invention of cigarettes. In 1851 Sir James Paget saw a patient with leukoplakia (then known as Smoker's Patch) near middle of dorsal surface of tongue where he always rested end of his pipe, and told him he certainly would have cancer of tongue if he

Letter: Misadventure during endotracheal anesthesia.

To the Editor.— InThe Journal(225:524, 1973), an accident caused by impaction of a suction catheter an endotracheal tube was reported. The catheter had become disconnected from its adapter during suctioning, while the thorax was open and the patient the left lateral position. When attempts to remove the catheter with clamps failed, extubation and reintubation with a new tube were performed. This, as the author states was a hazardous procedure since the patient was in the lateral position... obscured by drapes and his chest... open. Indeed, under the described conditions, intubation may be impossible and emergency tracheostomy too late. A faster and safer method is to slowly withdraw the endotracheal tube (with its impacted catheter) and then to cut 1.27-cm sections of the endotracheal tube until the catheter becomes visible. At this time, the catheter is grabbed and pulled back for 5.08 cm. A new endotracheal tube

Therapy of Osteoarthritis Of the Great Toe

To the Editor.— I would like to report the treatment of a woman suffering from postoperative osteoarthritis, with keloid formation and fibrosis and contracture of the metatarsophalangeal joints of both feet, especially of the hallux joint with apparent ankylosis. She had undergone surgery twice, unsuccessfully, within a year for hallux rigidus and hallux valgus, respectively. The result was that the feet were inflamed, swollen, and she was unable to walk. While desperately looking for help, I happened to see inThe Journal(217:215, 1971) a letter by Dr. Marvin Steinberg in which he recommended injections for such a condition. As prescribed by Dr. Steinberg, I administered injections of hyaluronidase and lidocaine around the joints and in the scarred areas for approximately two years. Initially, this treatment was done twice a week, but progressively less frequently until two months ago when treatment ceased. The result has been most gratifying in that

Thromboembolism after hip reconstruction.

To the Editor.— I was sorry to see the result reported by Evarts and Alfidi inThe Journal(225:515, 1973) on heparin prophylaxis of total hip reconstruction. I note that they have used Mr. Kakkar's program and not the one advocated by me.1His is a dangerous modification of my program and has created difficulties, as admitted by Mr. Kakkar2and by Mr. Charnley. Furthermore, Mr. Charnley has told me know that dextran doesn't work. I, on the other hand, guided by the findings of the pulmonary megakaryocytes and heparin controlled by the Dale and Laidlaw coagulometer, have experienced little difficulty. With my program giving 10,000 units of aqueous heparin subcutaneously the midnight before surgery and continuing postoperative small doses every six hours, not for just five to seven days as Mr. Kakkar recommends but until full reactivation or discharge, we have not had problems of hemorrhage

Treatment of Exercise-Induced Dysrhythmias in Patients With Pacemakers

To the Editor.— I read the interesting article, "Exercise-Induced Arrhythmias in Patients With Pacemakers," by Singer et al, published inThe Journal(224:1515, 1973). Myocardial ischaemia, sympathomimetic drugs, and stress such as recent operation are the factors described that such dysrhythmias may occur in patients with pacemakers in the absence of the above precipitating factors. 1 In three of my patients, exercise might have induced the dysrhythmias. Dysrhythmias following exercise might well be related to increased circulating catecholamine levels or increased sensitivity of the myocardium to catecholamines, practolol, being a specific, competitive antagonist of catecholamine at beta-receptor sites with a marked selectivity for those in the myocardium, 2 would be a useful prophylactic agent for the patients with exercise-induced dysrhythmias after pacemaker implantation. I have demonstrated the efficacy of practolol, and adrenergic beta-receptor related to propranolol, in the treatment of pacemaker-induced dysrhythmias and also suggested its use in dysrhythmia-prone patients

The cardiothoracic ratio.

To the Editor.— I am writing a letter to protest the first cardiovascular anachronisms mentioned in the article by that title by Dr. Marvin L. Daves inThe Journal(224:879, 1973). The first anachronism that Dr. Daves would like deleted concerns the cardiothoracic ratio. I would agree that probably this largely applies to chest films, but as I do it by cardiac fluoroscopy with orthodiagraphic attachments, I have found for many years that the cardiothoracic ratio can be relied on if it is consistently and carefully done. In my own patients I fluoroscopically take into account the motion of the diaphragm, the condition of the lungs, and the general and cardiac health of the individual. My technique is to look fluoroscopically at the entire chest first and have the patient take one or two deep breaths. I observe the position of the diaphragm and whether or not the left leaf is

Need for Clinical Pharmacologists

To the Editor.— We read with interest the EDITORIAL by Dykes inThe Journal(223:1497, 1973) and concur with him regarding the need for more clinical pharmacologists. Although Dr. Dykes' proposal to increase the number of clinical pharmacologists to fulfill the need would be the ideal approach, it is probably not the most practical nor the most feasible one. Dr. W.W. Oppelt is another practitioner who has been aware of difficulty in recruiting trainees into the field 1 as a major problem facing clinical pharmacology today. Perhaps the role of a consultant, although beneficial to the patient and the patient's physician, may not be sufficiently gratifying to the majority of physicians who want to specialize and be responsible for the final decision regarding the care and treatment of their patients. Furthermore, the prohibitive cost of training a sufficient number of graduate physicians to supply the demand necessitates consideration of an

Health in Sweden and the United States

To the Editor.— In answer to the article by Dr. Andrews, Jr., inThe Journal(223:1369, 1973), I believe he should have added the subtitle GruesomeLessons for America. Sweden isnotone of the healthiest nations in the world. Infant survival rate, a minor part of the health scene, is more a social than a medical problem. Then to compare that rate in a homogeneous little country to a heterogenous subcontinent like the United States is like comparing grapes to pumpkins. Compare Sweden to Utah if you wish, (their rates are about the same), or compare United States to Europe, (our rates are rather better), but not Sweden to the United States. Swedish socialists never mention rates that are unfavorable. They have significantly more deaths in Sweden from stomach ulcers and from pneumonia than we do here, but you have to search for these figures. Andrews' economic figures are

The Increasing Insurance Problem

To the Editor.— In response to the letter from Dr. George R. Ruiz inThe Journal(223:1391, 1973), I, too, decry the role played by insurance companies in establishing fees. Unfortunately, I see no simple solution. Insurance underwriting is a complex business, and medicine is a complex profession. As Chairman of the Blue Shield Committee of the North Carolina Medical Society, I have frequent opportunities to look at both sides of the coin. Insurance companies feel, not without reason, that procedural related fees are necessary for accurate underwriting purposes. In truth, physicians themselves demonstrate considerable variance among their fees for a given procedure. As pointed out by Dr. Ruiz, there may be legitimate reasons for this. However, if one sits on an adjudication committee one notes that every uterus is the biggest, every gallbladder the most demanding, and every appendix is retrocecal. Fees based on operating time invariably penalize the

Nuclear reactor safety.

To Editor.— A letter from Mr. Mustard commenting on nuclear reactor safety appeared inThe Journal(223:1158, 1973). His letter is full of errors of fact as well as interpretation. Mr. Mustard's letter begins with a reference to the fallacy of coal-fired plants creating radioactivity, and the fact is that coal-fired plants emit no fission products. That is his first error. Fission products result from fission of uranium fuel in reactor core. They are, of course, radioactive. Coal contains naturally occurring radioactive materials, particularly radium, uranium, and thorium, and these are indeed found in emissions from a coal burning plant. A recent report of National Academy of Engineering concludes: Comparing these quantities of natural activity released from fossil-fueled power plants with that from nuclear power plants on basis of hygienic equivalent quantities of typical radioisotopes associated with nuclear reactor operation, it is apparent that

Diagnosis of halothane hepatitis.

To the Editor.— The question of how to diagnose halothane hepatitis was asked inThe Journal(222:1192, 1972). From the opinions advanced, a reader unfamiliar with immunology could conclude that the disease is well defined. Thus, I want to comment accurately about the current status of halothane hepatitis. In so doing, I will, by the same token, invalidate the immunological criteria advanced by Dr. Schaffner because they are either nonspecific or have not yet been confirmed. Since most of the evidence proposed is derived from Dr. Paronetto's study, 1 I will refer to several points in his article. The positive lymphocyte transformation test (LTT), in eight out of 15 patients with halothane hepatitis, could not be reproduced by four separate groups as cited by Mathieu et al (unpublished data) and Davies et al and Bruce et al. 2 The patient and control groups in some instances differ marginally in their

The Air Transportable Hospital

To the Editor.— I read with interest Dr. Gerald A. Faich's article, Earthquake Brings Health Planning Lessons, inThe Journal(223:733, 1973). I would like to make a few comments regarding the medical care provided by the air transportable hospital. The personnel of the US Air Force's First Tactical Hospital, MacDill AFB, Fla, were notified at 4:00 PM on Dec 23, 1972 that they and the Air Transportable Hospital would be deployed to Managua to provide medical care for the earthquake victims. This Air Force, not US Army, hospital arrived via C-141 aircraft about 7:00 AM on Dec 24, 1972, and arrived on the grounds of the General Hospital at 11:00 AM. It was set up on a baseball field immediately adjacent to the rear of the General Hospital. The hospital had full capability for triage, casting, roentgenography, surgery, command, and two wards by 4:00 PM the afternoon of Dec 24.

Possible use of vitamins C and-or E in erythropoietic protoporphyria.

To the Editor.— The current interest in therapeutic vitamin supplementation has produced a confused picture with respect to porphyria. As noted by Mustajoki inThe Journal(221:714, 1972), the results of vitamin E therapy are contradictory. Thus, his group observed no clinical improvement in four patients with acute intermittent porphyria and one with variegate porphyria; whereas Nair et al 1 reported the successful use of vitamin E in porphyria. Ludwig 2 detected low tocopherol levels in persons with erythropoietic protoporphyria (EPP) and observed that the vitamin inhibited the in vitro photohemolysis of their red cells. This disease (EPP) is a good model for evaluating therapeutic agents, because it provides a sensitive in vivo criterion of efficacy (prevention of sunlight photosensitivity) as well as an in vitro standard (inhibition of erythrocyte photohemolysis). Provitamin A (β-carotene) has been employed successfully in EPP patients by Mathews-Roth et al. 3 Although the rationale for

Primer on the Rheumatic Diseases

A note on the genealogy of the Primer : This is the sixth Primer on the Rheumatic Diseases to be published inThe Journal of the American Medical Association . 1-5 The first of these six appeared in 1942 and was titled Primer on Arthritis . 1 This abecedarium, identified by its authors as the Second Primer on Arthritis, represented a revision of the Primer on Rheumatism, Chronic Arthritis , which had been issued in 1934 by the American Committee for the Control of Rheumatism (forerunner of the American Rheumatism Association Section of The Arthritis Foundation). This latter work, generally considered the first of the Primers , was a brochure that had been prepared for distribution in connection with a scientific exhibit on arthritis at the Annual Convention of the American Medical Association. 6 In fact, there were were two earlier publications in this line by the American Committee for the Control of Rheumatism. The first of these ( What is Rheumatism? ) was printed in 1928, and the second ( Rheumatism Primer: Chronic Arthritis ) was privately distributed in 1932. 6

Adverse Reactions to Drugs-- Not Just What, But How Often

The Boston Collaborative Drug Surveillance Program (BCDSP) and the methods it employs have been described previously inThe Journal.¹The program is designed to collect and analyze data on therapeutic and diagnostic drug usage in the medical wards of nine cooperating hospitals in three countries. While the goals are to reveal several aspects of information about drug usage, including the detection of unsuspected adverse reactions, a major purpose is to provide quantitative data on known reactions. If a prescribing physician is to make an intelligent appraisal of risks vs expected benefits from a drug, he needs at least a reasonable estimate of the likelihood of an undesired effect. Schemes for the spontaneous reporting of adverse reactions have generally proven futile in revealing any approximation of the incidence of a given reaction within the population exposed. The BCDSP, through careful monitoring of a finite patient population, provides a quantitative measure