AMERICAN MEDICAL ASSOCIATION ASSEMBLY

31

AMERICAN MEDICAL ASSOCIATION ASSEMBLY NOEL M. GUTTERIDGE THERE was an international atmosphere at Atlantic City, New Jersey, when 12,000 doctors met, between June 11 and 15, at this American counterpart of the French Riviera for the 100th annual session of the This city is composed American Medical Association. of a ribbon of palatial hotels, many of which are larger than any in London, scattered along a narrow strip of land edged by the celebrated five-mile boardwalk. This is a wooden promenade, some 60 feet wide, built over the higher part of the beach of the Atlantic Ocean. On to this boardwalk open the serried ranks of hotels, shops, cafes, shooting galleries, and slot-machine parlours. On the seaward side are three large piers devoted to amusement and entertainment. The focal point of the conference was the Convention Hall-or rather, series of halls. The main hall was occupied at the conference by the displays and booths of 500 teGhnical exhibits ; these are trade displays of commercial undertakings seeking professional contracts or goodwill. In the basement of the main hall was the scientific exhibit. Here, in 340 alcoves, were well-presented demonstrations on a wide variety of subjects ranging from the clinical evaluation of the ballistocardiogram, and the applications of electrokymography in the diagnosis of cardiac disease; cerebral angiography; orthostatic incontinence ; the lens hysteroscope ; skin, bone, and blood-vessel banks ; to the effects of ultrasonic energy on tissues. The general-practitioner section included exhibits of more general interest dealing with such subjects as iron-deficiency anaemia, hay-fever diagnosis, the therapy of cardiac failure, and the diagnosis and treatment of amenorrhoea. At most of the scientific exhibits reprints or summaries of the subject were distributed ; and leaders in medicine were in attendance to explain and amplify their exhibits. These were selected from 428 exhibits offered. In a part of the lower level of the Convention Hall operations and discussion clinics were presented by means of colour television. The morning programme included a csesarean section, a normal birth, appendicectomy, pneumonectomy, nephrectomy, and thoracotomy. In the afternoons 23 discussion clinics were shown, ranging over a wide variety of subjects from laryngeal lesions, replacement transfusion in the newborn, Addison’s disease, and liver biopsy, to phonocardiography and thyroid disease. One hundred doctors could see and hear at each of twenty television receivers, enabling 2000 to see the patient or details of an operation, blood films, histological sections, or radiographs, and to hear the commentary or discussion. The visual and acoustic reproduction were surprisingly clear, and one felt that it was possible to see the details as clearly as the operator himself. The television circuit began at the Atlantic City Hospital, and was conveyed by land-line to the Convention Hall. The Pennsylvania Hospital, whose staff was responsible for all the presentations, was celebrating its 200th anniversay as the first hospital in the - United States. Benjamin Franklin laid the foundation stone of the original building. In theatres, one on each side, of the Convention Hall, were screened each day 37 motion pictures on medical subjects, selected from 100 offered. Included in those shown was one sent by the British Medical Association, on infections of the hand, which was made by Prof. R. S Pilcher, of University College Hospital. Most of the motion pictures were with sound ; and the subjects included aphasia, surgical management of primary hyperthroidism, Hirschsprung’s disease, cleft palate, varicose veins, cesophageal diverticulum, and papillary "

.

"

carcinoma of the thyroid. The United States Public Health Service had prepared a sound film on the epidemiology of influenza, which included excerpts from a lecture by Dr. C. H. Andrewes, F.]P,.S. A.C.T.H. and Cortisone It was in Atlantic City, in 1949, that Hench and Kendall announced the discovery of these hormones.

Their

use in arthritis, skin disorders, ulcerative colitis, intractable bronchial asthma, allergic diseases, psychiatric disorders, disseminated sclerosis, experimental exophthalmos, ocular surgery, Addison’s disease, retrolental fibroplasia, sympathetic ophthalmia, and postoperative complications was discussed in eighteen papers to various sections.

ARTHRITIS

Prof. RUSSELL L. CECIL, of Cornell University, referred to this form of therapy as a " glorified aspirin." He does not use it for rheumatic fever, and he believes that three years must pass before it will be known whether ’ Cortisone’ prevents carditis. For the " incurable disease " of rheumatoid arthritis he advises gold salts in all early cases, and these should be used for the first three months. Cortisone may usually be given safely for one month ; after that troubles start. He advises under-treatment rather than the reverse. He thinks that " hyperadrenalism is not the answer to the rheumatoid-arthritis problem." " Hench and Kendall have only given us two more drugs to fumble with," he concluded. A. E. HANSEN, of Galveston, Texas, on the other hand, reported spectacular regression of acute rheumatic fever in children. He is confident that early rheumatic carditis will respond to A.C.T.H. E. M. MARTIN, of Rochester, Minn., urged the combined use of cortisone and physical medicine. ATOPIC DERMATITIS

atopic dermatitis the results are dramatic but temporary, reported T. H. STERNBERG, of Los Angeles. Prolonged maintenance therapy presents many unsolved In

problems. ADDISON’S

DISEASE

That Addison’s disease is now as controllable as diabetes, the view of P. S. 1IACNEAL, of Philadelphia, expressed in a televised discussion clinic. The administration by mouth of cortisone tablets slowly dissolved, should be controlled by eosinophil-counts. The dose should be kept between 50 and 75 mg. per day ; and the patient should also receive deoxycortone 25 mg. daily by mouth, in divided doses. Dosage should be controlled by the blood-pressure, amount of oedema, and body-weight. This combined therapy reduces pigmentation and increases general well-being. A patient under this therapy reported by television that she felt " jetwas

propelled." ULCERATIVE COLITIS

In ulcerative colitis SEYMOUR J. GRAY, of Boston, has had some good results in acutely ill patients with fever, leucocytosis, focal blood, diarrhoea, weight-loss, -and a high titre of lysozyme in the fseces. He advocates interval therapy. J. B. KIRSNER, of Chicago, has found that dramatic clinical improvement may result; but this is not a cure, for it does not alter the basic personality structure of the patient, nor does it seem to eliminate the factors promoting recurrence. Of 40 cases 35 were improved ; 15 had a sustained remission, and 5 had less good results. In all cases there was a well-marked reduction in the frequency of bowel actions. One patient, after therapy, went for 26 days without his bowels moving. Another patient " unaccountably " committed suicide while under therapy.

32 ALLERGIC DISEASES

PSYCHOLOGICAL EFFECT

F. J. BRACELAND, of Rochester, Minn., advanced the hypothesis that disruption of the internal metabolic homceostasis conditions the patient’s psychological responsivity during treatment with these hormones. DISORDERS OF THE NERVOUS SYSTEM

G. H. GLASER, of New York, has observed no changes signs or symptoms of progressive muscular atrophy, paralysis agitans, Kinnier Wilson’s disease, progressive bulbar paralysis, transverse myelitis, and Sydenham’s chorea, treated with cortisone or A.C.T.H. In myasthenia gravis and myotonia atrophica changes have been equivocal. In most cases of disseminated sclerosis bladder dysfunction was improved. in

EXPERIMENTAL EXOPHTHALMOS

S. 0. does not with the

DAYTON, jun., of Buffalo, said that

produce exophthalmos alone or purified thyrotropic hormone.

doses of cortisone-with 100 mg. reduced after a few days to 75 mg. or even 50 mg. per day. Patients with rheumatoid arthritis can be kept going on these lower doses for up to 15 months. It was felt that it was better not to start with big doses. The demand for cortisone is ten times the supply, and rationing of the drug can be expected for at least 2 years. Messrs. Merck & Co. are erecting a new factory, but a world-wide quota system is in operation.

are now

ROBERT A. CooKE and his group in Montreal find that these hormones effect temporary suppression of bronchial asthma, allergic dermatitis, urticaria, and drug allergies.

in

A.C.T.H.

conjunction

OPHTHALMIC DISORDERS B

H. E. THORPE, of Pittsburgh, has found the hormones valuable when surgery is necessary in acutely inflamed eyes. S. M. HAIK reported that sympathetic ophthalmia is controlled in some but not all cases. A. B. REESE, of New York, has obtained consistently encouraging results in the treatment of premature babies thought to be developing retrolental fibroplasia. ALLERGIC DISEASES IN CHILDREN

per

giving lower

day initially,

Plasma-volume Expanders To appreciate American interest in macro-molecular intravenous fluids one must understand that the U.S.A. is much more war-conscious than Great Britain. Airraid instructions are posted in public buildings, and siren tests are held in the large cities. For defence purposes the blood-collection target is 4 million pints per year, plus 3 million for civilian use. The defence collections in the past year were only a little over half the target, whereas in 1944 5 million pints were collected. In the past year the Red Cross has spent$3,000,000 on its blood programme, including new centres. The cost of collection is about$5 (S2) per pint (actually, 450 ml.). Up until a few months ago, 87% of the blood was collected by agencies other than the Red Cross; but the Red Cross proportion is now increasing. As in Australia, administrative difficulties between the Red Cross and other agencies are being ironed out. Processing of blood into plasma is being largely carried out by commercial organisations under contract. It is generally realised that there is not enough plasma or blood, even in peace-time ; and it is not possible to prepare or store enough plasma to meet a war need. Methods of sterilisation of plasma or blood are not well defined, and are not reliable. Ultraviolet irradiation has proved ineffective in practice. Nitrogen mustard has been shown not to affect the incidence of homologous’

‘

J. GLASER, of Rochester, N.Y., has had good results in allergic diseases in children who did not respond to the usual methods of treatment ; temporary remissions were produced. A.C.T.H. is valuable in temporarily clearing the skin of an eczematous patient to allow skin tests to be made. For childhood allergies dosage needs to be on an almost adult level. POSTOPERATIVE COMPLICATIONS

D. E. SZILAGYI, of Detroit, reported that A.C.T.H. has varying value in postoperative pulmonary oedema,

blood-transfusion reactions, and thyroid crises.

lower-nephron nephrosis,

TYPHOID FEVER

YALE KNEELAND, jun., of New York, remarked that when typhoid fever is treated with cortisone alone the resistance of the host is modified, but there is no antibiotic action on the organism ; the typhoid state is much improved, but the blood-culture remains positive for 4 days. With chloramphenicol alone the typhoid state starts to improve in 36 hours, and the temperature is normal in 4 days. With a combination of both forms of treatment the temperature is normal in 24 hours, and the typhoid state is lost immediately. COMPLICATIONS

the

complications described were silent gangrenous appendicitis, and perforation in ulcerative colitis. Stomach ulceration is a contra-indication to this therapy, owing to the danger of gastric haemorrhage. These Among

manifestations are due to interference with cellular reaction to injury and with fibroblastic activity. There may be concealment of overt manifestations of a psychosis, with suicide of an apparently euphoric patient. Unless a careful watch is kept for glycosuria the patient may pass into diabetic coma ; the diabetes can be controlled with insulin. In the conference on rheumatic diseases, which preceded the A.M.A. conference, it emerged that workers

serum

hepatitis following blood-transfusions, although

it will control other viruses ; and gamma-globulin, though an effective prophylactic against infective hepatitis, is not effective against homologous-serum hepatitis. The ideal plasma-volume expander should be nontoxic, and cause no histological change in the reticuloendothelial system, liver, kidney, or lung. It should not interfere with the clotting mechanism, and should " not cause the blood to sludge." It should be nonpyrogenic and non-antigenic. It should be readily metabolised, readily eliminated, and not stored in the body. Preferably it should contribute to the nitrogen balance. It should not interfere with blood-grouping and cross-matching. Acacia came into bad repute during the first world war, because it had not been fully investigated. The three types of expanders under consideration

proteins (gelatin), carbohydrate (dextran), and synthetic (polyvinylpyrrolidone [P.Y.P.]). The ideal molecular weight for an expander is about 65,000. The U.S. Armed Forces specification for dextran

are

is 80,000 with a tolerance of 25,000. Dextran as at present manufactured in Sweden has a molecular variation of from 20,000 to 200,000. Physically and chemically it is a polyglot material, and is not a uniform

product. Gelatin is the nearest to the ideal, but it has the serious disadvantage of forming a gel on storage. All three are acceptable in limited quantities of not more than 1-2 litres in 24 hours. The order of value is : gelatin, dextran, Dextran has been the most studied, and is the P.V.P. product which will be stock-piled by the Armed Forces in the U.S.A. A specification has been prepared. Clinically, dextran has given satisfactory, and sometimes dramatic, results. In the treatment of shock and in the " first-aid " treatment of haemorrhage it has been shown to cause a sustained increase in cardiac output ;

33 and

pressure is increased. There is no significant in glomerular-filtration rate, and the specific change gravity of the urine is increased. Impaired kidney function is not a contra-indication, and in normal subjects there is no diuresis. There is no clinical evidence that dextran damages the liver, and liver disease is, not aggravated by it. W. McK. CRAIG and his group in Rochester, Minn., have used 6% dextran in isotonic saline in over 2000 cases since 1946, and have found it of " tremendous value." They make it clear that dextran is not a substitute for blood, but it is a valuable adjunct. Colonel E. J. PULASKI, of San Antonio, Texas, has : established that dextran is antigenic to heavily immunised soldiers and " veterans;" in whom swelling of the face and some anaphylactic phenomena have been observed. These complications occurred with Swedish dextran, but not with the American product ; and they did not develop in anaesthetised patients. Dextran is valuable in the hypotensive state of anuria, and it has the advantage of not raising the level of the blood-urea. Twice the volume of 3% dextran effective than one volume of 6%. .FRANK W. HARTMAN, of Detroit, reviewed the tissue changes following the administration of dextran to animals and man. The animals received 1-8 g. of dextran. per kg. body-weight every 3 days for seven injections. Vacuolar degeneration of the interstitial tissues, comparable with sucrose necrosis, was found. Foam-cells developed in liver and kidneys. The blood-vessel walls, especially in the lungs, were infiltrated, and terminal chemical pneumonia might ensue. There was some desquamation and swelling of the convoluted tubules of the kidney. These changes are reversable in a few days. It is estimated that 38% of the dextran is excreted within 24 hours. One worker found that in man 1-2 litres of dextran daily for 3 days caused a 20% impairment of renal function Another worker found in tissue studies nothing significant, other than some temporary swelling of areolar tissue. Some of the dextran is phagocytosed by the reticuloendothelial system, and it infiltrates the tissues of the liver, spleen, lymph-nodes, and kidneys, mainly the endothelium of the blood-vessels. There is some doubt whether dextran is degraded in the tissues and metabolised. After two weeks no dextran remains in the body. (It seems certain that P.V.P. is not metabolised, and the fate of this substance is in venous

,

is more

doubt.) Within 3 hours of the injection of dextran, its concentration in the thoracic duct is almost equal to that in the blood. Its clinical value in maintaining plasmavolume seems to continue even when half the material is in the extravascular fluid. Electrophoretic studies of plasma and urine have showed no significant changes following dextran injection. Haemodilution takes place, as would be expected, and continues for 6 hours. Brevities

Under the age of 5 years more than half the cases of do not have jaundice-J. STOKES, jun., Columbus, Ga. Methods such as suspension for retroversion of the uterus and cauterisations of the cervix have little place in the treatment of infertility-F. B. CORDER, Durham, N.C. ’Azopyrin,’ a combination of sulphapyridine and salicylates, is one of the best sulpha drugs for ulcerative colitis-J. A. BARGEN, Rochester, Minn. In a group of 1000 doctors examined as patients in Tennessee, 68 cases of neoplastic disease were found. The time-lapse between the onset of clinical manifestations and the beginning of treatment compared unfavourably with that of the general population-B. F. BIRD, Nashville, Tenn.

hepatitis

The introduction of antibiotic therapy has changed the primary function of the infectious-disease laboratory. The question that now requires an answer is : What antibiotic is most likely to be effective ?1 The filterpaper disc method of study of susceptibility can usually supply the answer.-E. H. SPALDING, Philadelphia. The gap between retirement and death now stands at 51/Z years. This is double what it was in 1900. If the present trend continues it will be triple in 1975. Unless retirement policies are changed the individual worker will be faced with increased years of inactivity and with a drastically reduced income, under conditions which are physiologically and physically degenerative.S. C. FRANCO, New York. The air-evacuation aeroplane will play an increasingly important role in military planning operations. Its great speed, and ability to support sudden and unforeseen military evacuation requirements, are unmatched by surface means. It can make a major contribution to the lowering of mortality-rates.-Brigadier-General W. F. HALL, Washington. Chemotherapy in massive tuberculous pneumonia has completely altered the outlook in that serious condition. Patients with minimal pulmonary tuberculosis should not receive chemotherapy, because they will do as well with ordinary methods of treatment. Chemotherapy has exerted a particularly beneficial effect in tuberculous tracheobronchitis.—W. S. SCHwARTZ, Oteen, N.C. Washing powders, drainpipe cleaners, and some paint removers are serious poisoning hazards for children because they contain caustic soda. Less well recognised hazards are lactic acid, candy and chocolate cathartics, barbiturates, aspirin, aniline markings on diapers, crayons, shoe polish, moth-balls, and lead toys.-J. M. ANENA, Durham N.C. Shielding of the spleen from atomic radiation retains the activity of a splenic factor which favourably influences the recovery of the bone-marrow and the gastro-intestinal ’

mucosa.-Prof. C. McLEAN,

Chicago.

Public Health TUBERCULOSIS IN BUCKINGHAMSHIRE THE tuberculosis problem varies greatly from one part of the country to another. The crowded industrial cities of the Leeds region, described in our issue of June 23, present a very different picture from Buckinghamshire, packed well into the heart of England, with no large industrial cities, plenty of high ground, and a mainly rural community. This description applies to all but the southernmost part of the county, where Slough, indeed, presents a manufacturing community ; but the Slough area belongs to the North West Metropolitan Region, and this article deals with the rest of the county, which comes under the Oxford Regional Hospital Board. In the County Offices at Aylesbury, every patient with tuberculosis in this, the greater part of the county, is shown on a map by means of a coloured pin, put in at his dwelling-place (fig. 1). Besides showing that the bulk of the cases are in the towns, as would be expected, this map reveals at a glance the unexpected black spotsthe village with a cluster of 8 or 9 cases, the camp for displaced persons where the rate is greater than the average. FOR ALL WHO COME

thing about this county is exceptional. It is possible to lay a finger at random on any pin in the map and say : " This patient will never have to wait if he needs a hospital bed." This unusual state of affairs One

has been achieved in the course of the last five years, during which an effective tuberculosis scheme has been steadily developed. Prospects of a bed were not always.