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1967 Meeting Alaska State Medical Association--June 7-10— Sitka

23^997

Look how many ways

Thorazine*

brand of

chiorpromazine

can help

	Tranauiiizer	Potentiator	Antiemetic
Agitation	•
Alcoholism	•		•
Anxiety	•
Cancer patients	•	•	•
Severe neurodermatitis	•
Drug addiction withdrawal symptoms	•		•
Emotional disturbances (moderate to severe)	•
Nausea & vomiting	•		•
Neurological disorders	•
Obstetrics	•	•	•
Pain	•	•	•
Pediatrics	•	^ •	•
Porphyria	•	•
Psychiatric disorders	•
Hiccups— refractory	•
Senile agitation	#
Surgery	•	•	•
Tetanus	•	• 1

‘Thorazine’ is usefui as a specific adjuvant in the above named conditions.

The following is a brief precautionary statement. Before prescrib- ing, the physician should be familiar with the complete prescrib- ing information In SK4F literature or PDR. Contraindications: Comatose states or the presence of large amounts of C.N.S. depressants. Precautions: Potentiation of C.N.S. depressants may occur (reduce dosage of C.N.S. depressants when used concomitantly). Antiemetic effect may mask other conditions. Possibility of drowsiness should be borne in mind for patients who drive cars. etc. In pregnancy, use only when necessary to the welfare of the patient. Side Effects: Occasionally transitory drowsiness; dry mouth; nasal congestion; constipation; amenor- rhea; mild fever; hypotensive effects, sometimes severe with

I.M. administration; epinephrine effects may be reversed; derma- tological reactions; parkinsonism-like symptoms on high dosage (in rare instances, may persist); weight gain; miosis; lactation and moderate breast engorgement (in females on high dosages); and less frequently cholestatic jaundice. Side effects occurring rarely include: mydriasis; agranulocytosis; skin pigmentation, lenticular and corneal deposits (after prolonged substantial dosages).

For a comprehensive presentation of 'Thorazine' prescribing information and side effects reported with phenothiazine deriv- atives, please refer to SK4F literature or PDR.

Smith Kline & French Laboratories

I

Alaska Medicine, March, ]

Alaska MsdiciMe

Vol. 9, No. 1 March, 1967

EDITORIAL STAFF

[editor-in-chief

Arndt von Hippel, M.D. EDITOR

Theodore Shohl, M.D.

ASSISTANT EDITORS

Gilbert Blankinship, M.D. Walter Johnson, M.D.

CORRESPONDING EDITORS

Fairbanks —

Edward Meyer, M.D.

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Juneau —

Joseph O. Rude, M.D. Kodiak —

R. Holmes Johnson, M.D. Seward —

Ernest Gentles, M.D. Sitka —

Edward Spencer, M.D.

FEATURE EDITOR (Muktuk Morsels)

Arndt von Hippel, M.D.

COVER ARTIST

Marilyn Wilkins

COVER PHOTO

Billy Sturdevant, young musher from Anchorage, works his dogs the final yards of the Iditarod Centennial Trail race. Sturdevant placed third in field of 60 racers.

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Anchorage Daily News Photo |

PUBLISHING CONSULTANT

C. Herbert Rhodes }

BUSINESS and ADVERTISING

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Bob Ogden, Executive Secretarv 1

519 W. 8th St. s

Anchorage, Alaska 99501 |

Printed by

Anchorage Printing Company

TABLE OF CONTENTS

Page

LESTER HAROLD MARGETTS, Jr., M.D 1

GEORG WILHELM STELLER. PHYSICIAN-NATURALIST ON THE BERING EXPEDITION TO ALASKA

Robert Fortuine, M.D., Bethel, Alaska 2

MEDICAL ACTIVITY— ST. MARY'S MISSION

Adelaide A. Wiley, R.N 8

MUKTUK MORSELS

Arndt von Hippel, M.D 11

THE REGIONAL MEDICAL PROGRAM FOR HEART. CANCER AND STROKE

Donal Sparkman, M.D 14

PROFESSIONAL LIABILITY INSURANCE

Rodman Wilson, M.D 16

PROPOSED MEDICAL LIABILITY ACT

WITH COVER LETTER 18

LEGISLATIVE ABSTRACTS 19

EXTENSUALIS OBSTETRICUS, A FABLE

Anonymous 29

LIVER SCANNING

Bruce Wright, M.D 21

TENTH ANNUAL LEDERLE SYMPOSIUM

FOR ANCHORAGE 23

PERIPHERAL VASCULAR SURGERY IN REVIEW

Arndt von Hippel, M.D 25

NEW CARDIAC CATHETERIZATION LAB

Frederick R. Hood, M.D., and Arndt von Hippel, M.D 29

PRESIDENT'S PAGE

Robert H. Shuler, M.D., President ASMA 30

TRANSPORTATION POSSIBILITIES TO SITKA 31

CLASSIFIED AD SECTION 32

Alaska Medicine, March, 1967

VI

LESTER HAROLD MARGETTS, Jr., M. D.

Born: Spokane, Washington — May 14, 1922 Died: Anchorage, Alaska — January 31, 1967

Surgeon, gentleman, friend, all these were Les Margetts, and much more. He was cheerful and straightforward in all his relations with life. We will not be blessed with his like again. He was gifted with remarkable calmness during moments of emergency, in surgery and in all facets of life. Actually, in time of vital emergency he was un- usually good natured — more so than during the trivial irritations we all face day to day. In sur- gery this gift was well known to all his contem- poraries; in regards to other occasions may I mention the following incident. It occurred one threatening, dark and brooding evening on our return from Ugashik. Lake Clark Pass was closed. Jack Jefford, pilot and mutual friend, decided we would try flying through Bruin Bay. Ceilings were low and the wind became more awesome and turbulent with each passing of jagged peak and storm gashed bay. Seat belts were tightened as to almost interrupt circulation and straps grasped until knuckles were white. The plane was tossed about as a bubble in freshly opened cham- pagne. The wings now up, soon down, rarely level — stopped on each oscillation with a terrifying clump. Les remarked on this occasion, “Wouldn’t you think a pilot of Jack’s experience and ability could fly this ship without flapping the wings like a beheaded eagle.”

Les Margetts was a staunch, easy fitting and enduring friend — brave, manly, honest, under- standing, kind and learned. His death is a per- sonal, profound loss to all who called him friend. He died too soon, at the zenith of his fine work, and in full possession of his unusual talents, doing his best work — a splendid, irreplacable example for each of us. Had he lived longer, surely his gifts would have made him known beyond Alaska. He had many surgical firsts in Alaska and these were successful more because of his talents, courage and calmness than by reason of numbers of train- ed team members or white tower equipment.

He was not deeply opinionated — he had great respect for the views of others. His thoughts and his alone were not infallible — he could and did compromise. If his diagnosis was not correct or his treatment erroneous, he would frankly admit the mistake and did courageously strive to pre- vent a recurrence. A great and respected gift this, and one to be earnestly cultivated by each of us. Les was capable of open, bitter, and ample criti-

Dr. Les Margetts

cism of any who fostered injustice. He quarreled, but always wisely and never from pettiness or jealousy. In medical meetings he took a leading place, he was frank, forceful and literate in dis- cussion, and the more he was stirred, the more logical, cold and biting were his remarks. He was devastatingly truthful in meetings as at all other times. The truth would out even when most unpalatable. No actor, facts to him were unalter- able.

No thoughts of Les could be complete without mention of at least one of the innumerable per- sonal incidents in my relations with this man I could so proudly call a friend. Shortly after Les arrived in Alaska, he and I were hunting ducks over on the Susitna flats. It was a warm day recently bright but now dulled to a pink haze in the evening sun. We chatted side by side on a gray, gritty, tide-tossed log — now stranded by the ebbing tide. A flight of low flying Mallards inter- rupted us, alas too late. They approached like a formation of Delta winged jets and as soon were overhead. Our shotguns followed and were dis- charged as the flight passed beyond our backs. No birds fell. Unbalanced, Les and I were still side by side but now half submerged in a gray volcanic and organic sludge. He commented: “Say! That air to ground stuff is potent today.”

Carry on, Les — Friend, Man and Surgeon — until we who follow may also comprehend the secret of life which only death can reveal.

1

ALASKA MEDICI NE

GEORG WILHELM STELLER

Physician-Naturalist on the Bering Expedition to Alaska

It is appropriate in this Centennial Year to com- memorate a physician, Dr. G. W. Steller, who played a leading role in early exploration of Alaska. The following biographical sketch was written by an Alaskan physician who has spent a number of years in Western Alaska as PHS Service Unit Director at the Kanakanak and Bethel Hospitals. Dr. Fortuine is the author of several other papers on the history of Arctic medicine.

By Robert Fortuine, M. D.

Bethel, Alaska

“Good luck, thanks to my huntsman, placed in my hands a single specimen, of which I remember to have seen a likeness painted in lively colors and described in the newest account of birds and plants in the Carolinas . . . This bird proved to me that we were really in America.”

By this happy feat of memory G. W. Steller, Adjunct in Natural Sciences and Physician on the Second Bering Expedition confirmed that he had indeed reached the western coast of the New World. The bird in his hands was Cyanocilla sfelleri, now commonly known as Steller’s jay, one that bears a certain resemblance to the east- ern blue jay of the painting. The date was July 20, 1741, and the place Kayak Island, not far from the shimmering peak of Mt. St. Elias in Southeast Alaska.

Son of the village Cantor at Windsheim, Fran- conia, Georg Wilhelm Steller, or Stoeller as the family spelled the name, was born March 10, 1709. He attended the local Gymnasium where he graduated at the head of his class on Sept. 12, 1729, having excelled particularly in Latin. That same month he matriculated in theology at the Univer- sity of Wittenberg, but he soon became impatient with the narrow limits imposed on his inquiring mind by the Deistic faculty. In April of 1731 he therefore transferred to the University of Halle, where, though still nominally in theology, he was able to satisfy a growing interest in the natural sciences, particularly botany. He attended lec- tures in anatomy and other medical sciences during the next few years but did not take a degree in this field. His unusual aptitude for botany, however, qualified him to hold a series of lectures as a Privatdozent as early as May, 1732.

At the suggestion of Prof. Friedrich Hoffmann, Steller went to Berlin in 1734 to appear before Prof. Ludolf of the Obercollegium medicum in the hope of finding a university position as a botanist. Though easily passing his examinations, he failed

to secure the position he wanted at Halle, because of the illness of King Friedrich Wilhelm, who had to approve individually all such appointments.

Hearing that the Russian Army to the east needed surgeons, Steller traveled to Danzig where he was immediately enlisted and assigned to an artillery regiment. Within a short time, he was put in charge of a Russian transport carrying wounded soldiers across the Baltic to St. Peters- burg. After a stormy, thoroughly unpleasant pass- age, he arrived at the capital.

He soon met two very influential men, Johann Amman, the Professor of Botany at the newly established Academy of Sciences, and Archbishop Theophan Prokopovitch of Novogorod. The latter developed an immediate interest in the talented young man and took him into his household as a kind of protege, though Steller liked to think of himself more as a Leibmedicus to the prelate.

After several years of quiet study and botan- ical field work around the capital, Steller’s interest was roused by a massive undertaking jointly sponsored by the Academy of Sciences and the Imperial Government — The Second Kamchat- kan Expedition, which had departed in 1733 under the command of Vitus Bering to explore eastern Siberia and the surrounding waters. Steller fore- saw the great opportunities for botanical research on this venture and used every persuasive means in his power to get an appointment. Finally in February, 1737, with Amman as sponsor and with the influence of the Archbishop, Steller was named “Adjunct in Natural History” at a salary of 660 rubles a year “including quarters, firewood and light.”

In the fall he married a rich widow named Brigitta Messerschmidt, with whom he hoped to share his future adventures. They set out together in a troika in January, 1738, but by the time they reached Moscow, Brigitta had decided that the prospect of a Siberian winter did not have the appeal of the gay parlors of St. Petersburg. Sue accordingly left him and they never saw each other again. The pain of their separation did not last, however, for later, in Siberia, Steller was to write to his friend Gmelin, “ I have entirely for- gotten her and fallen in love with Nature.

The tedious journey across the expanse of Russia occupied more than two years. Steller became violently ill with a fever and nearly died

MARCH 1967

2

in Tomsk in the fall of 1738. After his recovery he pushed on to Yeniseisk where he spent seven weeks with the historian Gerhard Friedrich Mueller and the naturalist Johann Georg Gmelin, both of whom were about to terminate their par- ticipation in the expedition. Gmelin gave him a number of books for reference, among them the 1680 edition of Thomas Willis’s Opera Omnia.

Steller moved on through Irkutsk to Yakutsk, where he arrived in May, 1740. Along the way he continued to make botanical observations and collect specimens. By August he was at Okhotsk, where he met Bering and learned that he was unable to join the projected sea expedition to the east. Therefore he took a ship to Kamchatka, arriving at Bolsheretsk in early October. Thwart- ed in his desire to accompany Bering, he sent a petition to the Academy asking permission to join Capt. Spangberg, who was about to make a return voyage to Japan. While awaiting a reply he spent the winter studying the natural history of the Kamchatkan peninsula. In February, 1741, how- ever, all his plans suddenly changed when the Captain-Commander summoned him to Petropav- lovsk for a conference.

Bering, who was a Russian naval officer of Danish birth, was making final preparations for a voyage by sea from Kamchatka to confirm possi- ble reports of land to the eastward. His chief surgeon Caspar Feige had become too ill to make the journey, and remembering Steller’s “reputa- tion of being a skilled physician,” Bering decided to invite the young botanist along instead. He saw in Steller in addition a chance to fulfil one of the major charges of the Senate, which had been to collect and study the minerals of any new territory. Steller, though he dearly wanted to accompany Bering, was in a difficult situation, since he had already committed himself to go to Japan if the Senate consented. When Bering him- self insisted that he would take the entire respon- sibility, however, Steller signed on as a mineral- ogist to the expedition. In his unofficial duties as physician and naturalist, he was aided by Assist- ant Surgeon Betge and the draughtsman named Plenisner.

The two small ships, the Si. Peter and St. Paul, set sail to the eastward from Avacha Bay on June 4, 1741. The larger of the vessels, the St. Peter, with a crew of 76 men, was under the personal command of Bering, while the second ship was commanded by Capt. Chirikov.

The Captain-Commander apparently took an immediate liking to Steller and shared his own cabin with him. The young naturalist did not fare

so well with the crew, however. Almost from the beginning, Steller made himself unpopular and even an object of ridicule among the officers and men. His arrogance and thinly veiled contempt for their abilities as seamen and navigators were hardly calculated to raise their respect and af- fection for one who had never been on a voyage in the open sea. To his journal, which he kept throughout the voyage, Steller often confided his bitter feelings:

“The brazen and very vulgar snubs by the officers, who coarsely and sneeringly rejected all well-founded and timely admonishings and propo- sitions, thinking that they were still dealing with Cossacks and poor exiles freighting provisions . . . had been the cause of closing the mouth of myself as well as of others long ago.”

On June 20, the two ships became separated during the night and after a futile search for sev- eral days, the St. Peter struck out on its own in a southerly direction.

On July 16 land was sighted shortly after noon bearing north by west at a distance of about 120 nautical miles. This landfall was the St. Elias Range, dominated by the great volcanic peak of that name. Steller recorded the event rather bad- naturedly in his diary:

“We saw land as early as July 15, but because I was the first to announce it and because for- sooth it was not so distinct that a picture could be made of it, the announcement, as usual, was regarded as one of my peculiarities, yet on the following day, in very clear weather, it came into view in the same place.”

This sulky mood soon passed off when he realized the tremendous meaning of the new dis- covery. Here was the culmination of years of waiting and working, a completely unexplored land doubtless filled with new plants and animals — an almost endless challenge to the young natu- ralist. On the 19th, an island Bering named St. Elias (now Kayak) came into view and the follow- ing day, after a search for a suitable landing, the St. Peter dropped anchor under the lee of the western cape.

Quite incomprehensible to Steller was the attitude of the Captain-Commander, who, as he says, “shrugged his shoulders while looking at the land.” Bering was old, and the weight of his years had never felt heavier than now. After eight years of toil as leader of the Second Kamchatkan Expedition, Bering had come half way around the world over land and sea. His other ship was lost — maybe sunk — ^and even now the ship’s fresh water was more than half gone. The season, moreover.

3

ALASKA MEDICINE

was late in these northern waters. Bering was a tired man, and though inwardly pleased at having reached his goal, his first thought was to return at the earliest moment to protect his ship, his men and his discovery.

Bering finally decided to send ashore a water- ing party led by Master Khitrov, Steller’s worst enemy among the officers. At first he refused to permit the naturalist to accompany the longboat. In a fit of rage, Steller accused Bering of being interested only in “carrying American water to Asia” and threatened to report his conduct to the Senate and Admiralty “in the terms it deserved” upon their return. Such a public outburst to the captain’s face might have cost Steller his freedom or even his life, but Bering, who was probably more amused than offended by the outburst, finally consented to let Steller go, to fulfil one part in his own instructions, namely, to investi- gate the mineral resources of the region. He furthermore gave the Adjunct a little send-off from the rail by a flourish from his two trum- peters. That Steller was a little uncertain of how to take this display is shown by a note in his diary:

“Without hesitation I accepted the affair in the spirit in which it was ordered, as I have never been a braggart, nor would I care for such atten- tions even if they were really intended to honor me.”

Once ashore, Steller’s whole demeanor changed. Knowing that time was precious, he set about accomplishing as much as humanly possible. On the beach he found a hollowed log in which humans had cooked a meal with hot stones. Cari- bou bones were found nearby, along with mussels and bits of dried fish. Rushing inland with his Cossack, he discovered a native dwelling, a pit 12 feet deep covered by tree bark on poles, in which were utensils, sweet grass, thongs of seaweed and arrows. About an hour later he received an urgent message that if he did not retura immediately to the beach, he would be left behind. Instead he sent his Cossack off to shoot birds while he himself walked to the westward, returning at sunset. After another warning, he finally returned to the ship where to his great astonishment he was treated to chocolate by Bering in his cabin. He had been on Kayak Island for 10 hours, during which time he had seen positive signs of human occupancy and discovered many new plants and animals, among them the Alaska salmonberry and the Steller’s jay already mentioned.

The following morning at daybreak, Bering took advantage of favorable winds to leave before all the water casks were filled.

On August 2, the ship was close to a foggy island now called Chirikov I, in honor of the captain of the Si. Paul. Another struggle ensued between Steller and the Captain - Commander about going ashore, but this time no landing was made. On the 4th, a group of islands (The Semidisi was spotted, the waters of which abounded in fur seals, sea lions and sea otters.

On August 10, Assistant Surgeon Betge had a conference with the officers at which he reported 21 cases of scurvy among the crew, including five persons unfit for duty. Another council of officers was held Aug. 27 to consider the low water supply and the sickness of the men. A group of islands was sighted Aug. 29 and immediately preparations were made to go ashore. This time Steller found himself asked to accompany the party, as he notes in his diary, though characteristically he suspected that the officers wanted to share in the discoveries he expected to make. The sailors almost immediately began to fill the casks from a brackish pool, although Steller found several good springs. He insisted that the bad water would only worsen the scurvy and that its salinity would increase with age, even sending a sample of his spring water back to the ship. “But,” he wrote, “although in this matter I ought to have been listened to in my capacity of physician, nevertheless my proposition . . . was rejected from the old habit of contradicting.”

Nikolai Shumagin, a seaman, died August 31, the first victim of scurvy. He was buried ashore, giving his name to the island (now Nagai) and later to the group.

Steller, becoming increasingly exasperated by the turn of events, felt thwarted on all sides. He had been forced more and more into the medical duties yet found no support or resources for the task. “. . . I had made representations,” he wrote in his journal, “that our medicine chest, from the very beginning, had been miserably supplied, inasmuch as it was mostly filled with plasters, ointment, oils and other surgical remedies enough for four to five hundred men in case of a battle, but had none whatever of the medicines most needed on sea voyages and serviceable against scurvy and asthma, our commonest cases; . . .” He asked for a detail of men to help him collect antiscorbutic herbs ashore but the request was not granted, though later, he recalled, when there were only a few able-bodied men remaining on board, “I was tearfully begged to help and assist, which then, though with empty hands, I did to the utmost of my strength and means . . .” His real and imagined wrongs finally led to an

MARCH 1967

4

unworthy resolve; . . when I saw my opinion concerning the water again spurned and coarsely contradicted and had to hear myself, like a sur- geon’s apprentice belonging to the command, ordered to gather the herbs, and that this im- portant work, which affected the health and lives of all, was not considered worth the labor of a few sailors, I repented of my good intentions and resolved that in the future I would only look after the preservation of my own self without wasting another word.”

These bitter reflections were interrupted on Sept. 5 by the appearance of natives for the first time. The ship had finished watering and had attempted unsuccessfully to depart, but because of adverse winds it had had to heave to and anchor off the north end of Bird Island. Two natives, in small skin boats not unlike those of the Green- landers, paddled to the ship and exchanged trin- kets with the crew. After some attempt at com- munication, Steller, Lt. Waxell and others rowed ashore with them but were unable to land their boat because of the rocks and surf. Instead, several went ashore in the water and were well received by the natives who gave them whale blubber as a token of friendship. The brandy offered in return was spat out in disgust. When the sailors finally attempted to return to the boat, the natives misunderstood their actions and pre- vented them from leaving until a shot was fired over their heads, whereupon they fell down as if dead.

These aboriginal inhabitants of the Aleutians were described by Steller as medium in stature, plump, well-proportioned and with black eyes, glossy straight black hair and flat noses.

The St. Peter got under way the next day, plodding southward for a few days, then veering westward again. Day by day new cases of scurvy appeared. Bering himself became so sick that he entirely lost the use of his limbs. Steller, however, despite his earlier threats, administered some of his personal supply of spoonwort, collected at Nagai, to the Captain-Commander, with the result that within eight days he was able to go on deck again.

Beginning Sept. 25, a severe storm arose, pounding the little ship with whistling winds and mountainous seas for more than two weeks. By this time over twenty persons were incapacitated by sickness, leaving barely enough crew to man- age the ship. For most of the storm the little vessel wallowed out of control. “There was much praying,” observed Steller wryly, “but the curses

piled up during ten years in Siberia prevented j any response.”

By mid-October, 29 men were on the sick list. Lt. Waxell, second in command, tried to convince Bering, who himself was still badly laid up with the scurvy, that the ship should winter in Amer- ica but the old man grimly decided to push on. Morale was at a very low ebb indeed. Steller confided to his journal “misery and death sud- denly got the upper hand on our ship . . . The small allowance of water, the lack of biscuits and brandy, the cold, dampness, nakedness, vermin, fright, and terror were not the least important causes.” On Oct. 25 they sighted an island, prob- ably Kiska, and considered going ashore for water, but it was conceded that the crew was too weak to weigh the anchor once it had been dropped. By Nov. 3, there were so many sick that it was scarcely possible to make any changes in the sails.

On Nov. 5, land was sighted again, this time a small island, followed shortly by a larger one, in what is now known as the Commander Group. A council of the officers was held. Bering, who was very weak, aroused himself with some ex- citement and talked optimistically of an early release for all from the miseries of the voyage. He felt that they were so close to Kamchatka now that it would be foolish not to go on. Only one officer agreed. With 12 men already dead and 34 totally disabled for duty, and with only six casks of bad water remaining, the consensus was to spend the winter ashore rather than to take a chance on the open sea again. At last Steller was invited to speak. The former slights still rankled: j “I have never been consulted in anything from the beginning, nor will my advice be taken if it does not agree with what is wanted; besides the gentlemen themselves say that I am not a sailor; therefore, I would rather not say anything.” His journal continued: “I was next asked if I, as a person worthy of belief (being now for the first j time so considered) would not at least add a j written certificate regarding the sickness and the miserable condition of the crew. — This I therefore undertook to do, in accord with my conscience.”

Finally, on November 6, the resolve to stay was firmly taken and the anchor dropped into the waters of the natural harbor. Steller went ashore the next day, along with a number of the sickest ! members of the crew. Bering himself, in critical | condition, was brought ashore two days later. The f next few weeks were spent in unloading the ship f and making preparations for the winter’ which j was already close upon the wretched band. Many |

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ALASKA MEDICINE [

5

died as they were brought into the fresh air to come ashore, no fewer than four on one day. “Some of the sick,” Steller relates, “cried because they were cold, others because hungry and thirsty, since the mouths of many were so miserably affected by the scurvy that they could not eat anything because of the great pain, as the gums were swollen like a sponge, brown black, grown over the teeth and covering them.”

Fresh food now was abundant, although it was difficult to find the strength to obtain it. Ptar- migan, sea birds, and sea mammals were plentiful. Steller caught a sea otter on the 12th, which he tried to share with Bering, but the old man preferred ptarmigan and would not touch it. The last of the sick were brought on shore November 15.

Steller built a shelter for himself, Pienisner, the draughtsman, Betge and several others. Mas- ter Khitrov, himself ill with scurvy, asked to be taken in but Steller refused since his old enemy was “mostly sick from laziness and was the chief author of our misfortunes.” Lt. Waxell, on the other hand, Steller tried his utmost to preserve for fear that otherwise Khitrov might succeed to the command.

On November 28, a gale drove the ship ashore, destroying at last any hope of reaching home that year. It was a sorry group huddled together in the damp, raw wind, exhausted, almost naked and plagued by illness and despair.

Blue foxes were everywhere. They had no fear of man, nibbling on toes, eating provisions, and chewing on corpses. Steller himself killed over 200 of them and seemed to take a cruel pleasure with the others in torturing them. “Some,” he said, “were singed, others flogged to death . . . It is most ludicrous when, being held by the tail they pull with all their might and someone then cuts off the tail . . . Nevertheless they could not be warned.”

The Captain-Commander died early in the morning of December 8. Steller was perhaps more touched than anyone at the passing of the old gentleman, who, he said “perished rather from hunger, cold, thirst, vermin and grief than from any disease.” To which in his diary he appended a rather tedious account of his agonal pathological state. The young scientist recognized clearly the debt he owed him. “The only blame,” Steller remarked, “which can be laid against this excel- lent man is that by his too lenient command he did as much harm as his subordinates by their too impetuous and often thoughtless action.” Bering

was buried under a simple cross on the hillside and his men named in his honor the island which claimed his remains.

Steller’s true talents were belatedly recognized by the crew, once they could see his inordinate skill in making the best of the situation in which they all found themselves. They looked to him for help in building a shelter, finding water and killing game for food. Once off the ship and especially after Bering’s death, many looked on him as their leader, though Lt. Waxell had offi- cially succeeded to the command.

Nor were Steller’s efforts wholly directed toward subsistence. He took a lively interest in the island and its unique natural history, taking voluminous and precise notes, later published, on the climate, plants, birds, mammals and fish. Sea mammals held his attention especially. While on the island, he described no less than four such animals new to science. Two of these, the sea otter and the northern fur seal, were to have a tremendous economic importance for the Rus- sians in the New World. Two more have been given the name of the scientist himself — the Steller sea-lion and the Steller sea-cow. The latter was a unique animal which became extinct by wanton slaughter a mere 27 years after its discovery. A number of these creatures were har- pooned for food and one weighing an estimated 8,800 pounds and measuring over 24 feet in length was dissected and described by Steller, the sole scientific record of the species. His notes on sea mammals were published after his death under the title De bestiis marinis (1751). His observations on birds produced at least two more new to science in addition to the jay — the spectacled cormorant, now extinct, and the beautiful little Steller’s eider.

His botanical discoveries are more difficult to appreciate today, since his descriptions antedated the binomial system and classification propound- ed by Linnaeus only a few years later. Steller made an extensive list of the plants found on the island, as well as collecting numerous specimens, some of which later reached St. Petersburg.

In April a council of officers was held to determine the best course of action to be taken. It was decided to break up the St. Peter, and re- build a much smaller vessel, in which they would attempt to reach the coast of Kamchatka. With the unfolding of spring, spirits and hopes fresh- ened considerably. Several of the men had only now fully recovered from scurvy when given fresh greens collected by Steller.

MARCH 1967

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On the 5th of May, the sternpost was erected of the “Hooker St. Peter.” After work into the summer, all was at last in readiness for the launching, which took place on August 10, 1742. Three days later the little craft with 45 survivors set sail for the west, arriving at the harbor of Petropavlovsk on the 27th of August.

Steller’s subsequent life may be briefly told. The following two years he worked out of Bol- sheretsk exporing, writing and botanizing, and even making a trip to the Kurile Islands, while waiting for news from St. Petersburg. The expe- dition was officially disbanded by an Impei’ial Ukase of Sept. 23, 1743. Steller later received his orders from the Academy of Sciences to return to St. Petersburg via Yakutsk, Tomsk, and then down Irtish River to Tobolsk, with special atten- tion to describing the fish and plants on the way.

In the spring of 1744, while still at Bolsheretsk, Steller quarreled with a midshipman named Khmetevski, who, with the departure of Lt. Waxell, had become the ranking naval authority over the remainder of the expedition. Both men sent versions of their charges to the Governing Senate, Steller being accused of releasing without authority some Kamchadal rebels.

With sixteen packing cases of manuscripts and specimens, Steller finally left Kamchatka for Okhotsk by ship, on Aug. 3, 1744, and by October had reached Yakutsk, where he spent the winter. By the fall of 1745 he had reached Irkutsk. At this city he faced the charges brought against him by Khmetevski and was duly acquitted by the Vice Governor. Through an unfortunate delay, how- ever, the news was not promptly forwarded to the capital, with the result that the following year, which found him far to the westward in the Ural Mountains, he was arrested by an Imperial emissary as an apparent fugitive from justice. Despite his bitter protests, Steller was accord- ingly escorted toward Irkutsk, to stand trial again. On the way, east of Tobolsk, another messenger caught up with the party with orders for Steller’s release. He remained in Tobolsk for about three weeks, drinking heavily, and then set off to the westward once more against the advice of his friends. Burning with fever, he reached Tyumen, where despite the care of the Surgeon Lau of the St. Paul, who by an extraordinary coincidence happened to be in the town, he died on November 12, 1746, at the age of 37. He v/as buried just outside of town, overlooking the river.

Steller’s place in history remains secure on the basis of his work as a botanist and zoologist in

Siberia, Kamchatka, Alaska, and above all Bering Island. The sea mammals of the northern Pacific will always be associated with his name. Linnaeus, the great Swedish botanist and systematist, called him “a born collector of plants” and in a letter to Gmelin urged the latter to adopt the genus name Slelleria, since “Everyone in the botanical world who knows plants loves Mr. Steller.”

Unfortunately, as the record shows, Steller the man was not so lovable. He could be vain, arrogant, cruel, ambitious, selfish, and short- tempered. An intense, humorless man, he was impatient with anyone who stood in his way. This desire for success made him a good scientist but a bad companion, and indeed, Steller did his best scientific work alone under field conditions. For a man of his temperament and education, a long sea voyage under cramped conditions and among coarse unlettered seamen was bound to bring out the worst in his nature. It is unfortunate in tiiis regard that most of the personal records that remain of Steller’s views and attitudes are taken from his own diaries and other recollections of the Bering Expedition, where life was full of hardships and frustrations.

Perhaps they give a slanted view, since in his earlier life many prominent men of learning had sought his friendship. His positive qualities also became apparent during the long sojourn on Bering Island, where his skill, courage and re- sourcefulness may have salvaged the expedition from total destruction. Bering himself of course recognized Steller’s abilitiy and was willing to overlook his impetuosity and pettiness. So did Lt. Waxell, who having seen him at his best and worst, called him years after the expedition “a great botanist and anatomist, well versed in natural science.”

Steller died tragically in the prime of life. His name, however, will perhaps always be linked with that of Bering and associated with the unique plants and animals of the North Pacific region.

References

]. Goliler, F. Bering’s Voyages, An Account of the Efforts of the Russians to Determine the Relation of Asia and America, .iimeiicau Googiapliical Society (.\ew York, 1922) 2 vol. oTl pp. 291 pi>.

2. Stejneger. T.eonliard: Georg Wilhelm Steller, the Pioneer of Alaskan Natural History. Harvard (Cambridge, JJass., 19:16) 62:i pii.

:l. Steller, G. W. De bestiis marinis. (St. Feter.sburg, ITTG). 4. Steller, G. W. Letter to Gmelin. Nov. 4, 1 742. In: Colder op cit. Vol. II p. 242-249.

.7. Steller, G. W. "Steller's Journal of Hi.s Sea Voyage from the Harbor of Petropavlovsk in K;(mchatka to the Western Coasts of America and the Happenings on the Return 7'oyage.” In: Colder, op. cit. Vol. H, p. 9-187.

6. Steller. G. W. "Topographical and Physical Hescrintion of llering Island Which Lies in the Eastern Sea Off the Coast of Kamchatka." In: Colder op. cit. Vol. II p. 1 89-241.

7. Waxell, Sven; The American Expedition. Wm. Hodge K- Co. Lt. (London. 1 9.72) 2:56 pp.

/

ALASKA MEDICINE

MEDICAL ACTIVITY— ST. MARY'S MISSION

St. Mary’s Mission is a school on the Andriefski River, first left turn off the Yukon going down from Pilot Station. There are over 200 students, mostly eskimo, with about 130 boarders from the lower Yukon and Kuskokwim and another 100 day students from the immediate area. Medical activity includes giving care for the Mission boarders and personnel numbering about 160, St. Mary’s Village with a population of 285, Pitka’s Point around a 6-mile corner on the Yukon with a population of 50 and people living at points between totaling about 35. The nearest hospital and doctor are 100 miles south at Bethel, reached only by plane and contacted only by radio. Medical personnel include a medical aide elected by the village council and a registered nurse who volunteered as school nurse for St. Mary’s Mission School.

By Adelaide A. Wiley, R. N.

BSN ’62 Georgetown U. School of Nursing

Present Mission Nurse

A look at the mission clinic’s log gives some idea of the medical activity at St. Mary’s. Glanc- ing through we see that the number of patients visiting the clinic daily runs about 25. The week averaging 75 visits a day represents a flu epidemic with patients lined up into the hall waiting to have their temperatures taken with only 30 ther- mometers and whole dorms turned into infirm- aries. Eight clinic visits represent a holiday.

Included in these visits are a few students with headaches, a girl with dysmenorrhea, a squint-eyed basketball player holding the remains of a pair of glasses, an alert first grader with sores that require cleaning, and an exhausted girl with a hacking cough. Frequently a youngster comes in with nausea and vomiting or diar- rhea. A stomach ache along with this raises the question — is it or isn’t it? Appendicitis that is. Once appendicitis was occurring in “epidemic” proportions with two students sent to the hospital and operated on in five days. And this in the middle of a very real intestinal “flu” epidemic. Then there are the daily visits of a 7th grader with a history of draining ears for the last seven years. Occasionally a brave little girl is at the door fighting back the tears as she holds onto her ear for all she’s worth. Or a second grade boy i§ sent up as he isn’t concentrating in class due to a rotten tooth. A stream of cuts and burns come in from the kitchen and bakery area. Basketball daj's bring in a fair number of abrasions. And with 60 boys in the dorm, a few black eyes are seen. Naturally these are all acquired from run- ning into the door. And being in the climate it is, the log also records a few cases of frostbite.

Sprinkled throughout the log are more serious problems. Pneumonias turn up pretty frequently. Recorded here and there are fractured collar- bones, severe dog bites, and injuries resulting from ski-dos and sleds tipping over. As most of the fuel in the area for heat and cooking is wood, axe injuries are not uncommon.

Treatments as recorded show that pHisohex scrubs and DSD take care of most things. Butter- flies take the place of stitches. Tongue blades splint fingers and wrists and broom sticks handle anything bigger. Soaks have their place being used for sprained ankles, burns, frostbite, injured fingers, puncture wounds, cellulitis, preliminary treatment for scrubbing up areas of impetigo, sore eyes, sitz baths, infected wounds, and dermatitis. One day on record there are nine soaks. What the record does not tell is that seven of these had to be done at the same time in a clinic where +hree is a crowd, with regular clinic traffic coming and going. Hot water bottles are passed out at night for tooth aches, ear aches, back aches, and chest pain. Ice packs are prepared as needed for head injuries, sprains, acute abdomens and nose bleeds.

On the medicine shelf is found aspirin. Last year 15,000 were given out. Metimyd is the stand- by eye ointment. All that is red is not PKC, but up here the odds are for it. Bacitracin is used on infections, desenex on feet. Penicillin treats most of the pneumonias, acute ear infections, sore throats, cellulitis, and wound infections. Penicillin is also used prophylactically for a few with his- tories of rheumatic fever and one with Henoch- Schoenlein syndrome. Benadryl is the stand-by for allergies and hives which show up rather frequently. Gelusil does wonders for stomach aches occurring about exam time or just before a speech class. Other medicine is used, but not as frequently.

Not in the log, but possibly given out in bigger doses than anything else is TLC. No boarding school can escape a few cases of homesickness or loneliness. And there, are the younger students who' come in physically hurt it is true, but whose pride is hurt more, as not only wefe they whacked on the head by a broom, it was their best friend that did it! Or possibly the fall that cut up their shins “let that guy get away when I was just close.” From the older students comes a knock on the door and a request for aspirin, but what might be needed more is a good ear.

MARCH 1967

8

Lab work at present is limited. Combi-stix, hemo-stix, and a Hgb-Meter accounts for most of it. An occasional WBC is done on someone with an acute abdomen when there’s an anticipated wait of 12 hours before a doctor or plane can be contacted. Sputums are sent to labs in Anchorage for AFB. An occasional slide and blood sample are sent to Bethel Hospital. Once Bethel Hospital was the recipient of one well wrapped dog’s head.

On the margin of the pages in the log are found such notes as 3 pairs glasses sent for repairs, 4 sputum cans sent in, drug order sent, 2 begging letters written, received donation of vitamins, or letter to doctor regarding 5 patients. Or such notes as 20 Snellen screening tests and 15 audio- grams done might be found. 33'/^ of the students have a hearing loss in one or both ears greater than 30 decibels and most of these have a history of draining ears. Or there might be notes like grade school weighed, student records brought up to date, or clinic cleaned.

Sometimes as often as five times a week or even three times a day are found names listed with village and a number written after it. These represent the home visits and the time spent there. The time may be 1 hour, 2 hours, and once 10 hours. This last was a call from Mt. Village. The record does not tell that this includes travel time which is by kicker boat or sled depending on the season, feet if no other transportation available for the call one mile and more away and naturally for the calls in the village proper.

And as frequently there are notes regarding medical traffic — 3V2 hour stand-by with two pa- tients reported, or radio medical traffic 3 hours stand-by, no contact as poor reception. Sometimes this last note occurs day after day once week after week. Not recorded is the winter tempera- tures of the radio room which are sometimes 38°F at head level and below freezing at foot level.

Now and again it is recorded that a doctor is here. This may be the regular annual field trip of a doctor from Bethel Hospital with a 4-day stay or a doctor from Arctic Health on a research project requiring a two-day stay. Or possibly it’s Doctor Fritz from Anchorage who last year in 4 days prescribed 92 glasses for 94 students seen out of an enrollment of 224, some of these already having glasses and leaving 42 students not seen for lack of time. Dr. Carpenter’s annual two-week stay working on teeth is duly recorded. Once a field chest clinic was held here. And once a doctor was stranded — a gift from heaven.

Once a year the record shows the x-ray team

came. Often it is noted that a nurse is visiting. This may be the Alaska Department of Health’s itinerant nurse on her field trip or an Arctic Health nurse working on a special project. Or it might be the mission’s traveling nurses in between trips. Working from the mission these nurses go as a pair to the neighboring villages for visits lasting up to two weeks. Once there they teach catechism and modified medical self-help to the villagers. Much of their time is spent visiting which gives an opportunity to do health teaching on a one to one basis which has been found to give the best results. While in a village they are often consulted on particular health problems occurring during their stay.

Also on record are patients going and coming from the hospital. One day six were flown out to the hospital — a boy with psychotic-like symp- toms, a child with dog bites from a possible rabid dog, two villagers found to have active TB, one woman with a threatened miscarriage, and a 4th grader with partial facial paralysis and a long history of draining ears. Just six days later three more villagers went out with active TB, a mother with a history of previous complications to await delivery near a hospital, a baby with pneumonia, and a woman with severe headaches.

Over several periods of time notes appear that medical classes were held for the village medical aides or that Medical Self-Help was taught to the freshmen.

This is all work involving the mission nurse, some of it more completely than others. In regards to the villagers the mission nurse works with the village medical-aide, seeing only those patients about which the medical aide asks advice or refer- ring someone to the medical aide when medical assistance is indicated. When the nurse does see villagers or goes on sick calls in the village she tries to teach the medical aide so that the next time the medical aide will be able to go ahead and handle a similar situation herself. Specifically in regards to OB patients, the nurse works with the village midwife, again trying to teach as the occasion arises. It is a situation where the mid- wife has the experience, the nurse the book knowl- edge and hopefully a mother with a command of English and Eskimo. In the last year there are records of five home deliveries and most of the mothers go to the hospital. One delivery on record has a notation that the placenta was retained for seven hours. Off the record it took 84 miles of kicker rides making seven round trips between patient and radio to get the situation taken care

9

ALASKA MEDICI NE

of. Another delivery required crossing a slough during break-up in the dark to get there. In this area, with regards to the OB patients, an ounce of prevention is worth a ton of cure. So once a month a note is found in the log — Pre-natal clinic held — five, six or possibly even 12 seen. The number depends on the time of year.

In regards to visits by others in the medical profession the mission nurse helps as needed as prescreening in anticipation of the eye doctor’s visit, sending for needed people, keeping track of the census for both mission, village, and sur- rounding area especially for the x-ray team and immunization programs to get as close to lOO'/f participation as possible. Or the mission nurse may help give the immunizations. In preparation for the dentist’s visit she gets the dental clinic, which serves as a storeroom in between times, cleared and scrubbed.

Specifically regarding the mission students and personnel, the mission nurse takes full charge of those sick giving all treatments, medicines, and nursing care as ordered or indicated. This involves carrying food trays, preparing hot water bottles and ice packs, packing water, many a watchful night, and very often a lot of foot work. Also volumes of paper work are involved —

getting records, keeping them up to date, filing, drug orders, letters to doctors. Attempts are made to keep the necessary medical supplies in stock. This is done by begging, borrowing, but as yet no stealing. And there is always the clinic itself to be kept clean and in order along with the equip- ment in it.

A bright spot on the mission nurse’s calendar is the return of the mission’s traveling nurses. With their return the work is divided. Without their help the mission activity might not be as great as it is now recorded in the mission clinic’s log.

BACKGROUND ON ADELAIDE WILEY, R. N.

Now 26 years old and in her third year as a volun- teer nurse at St. Mary’s Mission, Miss Wiley is a graduate of Georgetown School of Nursing, Washing- ton, D.C. Her father, John Preston Wiley, is an officer in the State Department. Prior to her work at St. Mary’s Miss Wiley was a $6,000-a-year nurse at U.S.P.H.S. Hospitals in Kotzebue and Mt. Edgecumbe. For her work at St. Mary’s she receives room and board and the right to draw on the Mission store for stamps and stationery. During the summer of 1965 she conducted medical aid courses for adults in the villages of Stebbins and St. Michael on the Yukon delta. On her rare visits to Anchorage, Miss Wiley rates a big hamburger and hot fudge sundae as major attractions.

I Hotel reservations for your stay in Sitka during ^

•» *♦

i the Annual Meeting, June 7-10, 1967, should be ^

^ »»

«»

I made as soon as possible. Pat Sarvela, Dr. T. M. ^

? ?

5 Moore's office nurse, has volunteered to help with ?

I this vital task. Write now for your reservations: f

I Pat Sarvela, R. N., Box 1000, Sitka, Alaska.

MARCH 1967

10

Anchorage Medical News has been over- shadowed by the sudden and untimely death of Dr. Les Margeiis. In his 12 years of active surgical practice in Anchorage Les had become a loved and respected community figure.

Dr. William Mills was awarded the Bronze Star for bravery in the diagnosis and treatment of a South Vietnamese marine with a huge subcutan- eous mass of recent onset. Because of his language problem, the patient kept thumping the mass, which absorbed Bill’s attention completely when he discovered that it was a live mortar shell. Apparently on his way to South Vietnam for a six month tour is Dr. Alan Homay. We expect more information shortly. Dr. Marcell Jackson has resigned from the Doctors Clinic and has taken over Dr. Homay’s practice.

Dr. Donald R. Rogers of Seattle, a board quali- fied pathologist, has joined the Doctors Clinic in Anchorage. Dr. Merritt Starr has taken over the State Medical Society T-V program series. Dr. Elizabeth Tower has resigned as Editor-in-chief of Alaska Medicine after many productive years of labor on the editorial rock pile. The many duties that she so ably performed will be divided between the new editor and Mr. Bob Ogden. Mr. Ogden is the new Alaska State Medical Society executive secretary. He was most recently the business manager of the Juneau Clinic and chair- man of the Juneau Hospital Committee.

Dr. Grace Jansen recently was married to Vin Hoeman, a well known American mountaineer whose ideas of comfort are off by about 100 degrees (fahrenheit). Dr. Bruce Wright recently married Nancy Allison of Anchorage. Drs. Fred Hillman and Louise Ormond Hillman have adopt- ed an infant son. Dr. Richard Paul had his second son I third child) and Dr. Paul Dittrich recently had his first child, a boy.

We hear that Drs. Robert and Helen Whaley are reserving their decision on returning to An- chorage pending clarification of medical liability issues and legislation. Many Alaskan physicians share their doubts on continuing medical practice in Alaska under present circumstances.

As February ends Dr. George Wichman is reported above 17,000 feet with a group of moun- taineers making the first winter ascent ever at- tempted of Mt. McKinley. We will have more on this later.

Dr. Harold Bartko has gone to Nome from An- chorage and will work at the Maynard McDougall Memorial Hospital. At present he is the only physician in Nome. He was recently appointed to the Alaska State Health Facilities Advisory Coun- cil by Governor Hickel.

From Seldovia we learn of the recent death of Mrs. Florence Armstrong. Dr. O. H. Armstrong is reported out of the state at present. Dr. John Fenger of Homer is taking a two-year residency in Physical Medicine and Rehabilitation at the University of Washington. (P. O. Box 758, Bothell, Washington). Dr. Joseph Deisher visited Seward in December and then returned to the Marshall Islands for the last months of his tour there. Dr. Deisher plans to take a fellowship at the Univer- sity of Illinois in Continuing Medical Education as preparation for a position as Director of Medi- cal Education.

Dr. Bob Johnson of Kodiak was appointed to the Alaska Board of Basic Sciences. Dr. David Sammann left Skagway in December for graduate work at the University of Washington. He expects to return in April.

Dr. Joseph Rude has retired from the Doctors Clinic in Juneau. His son, Dr. Donald Rude, passed his Boards in surgery and is now practicing in Swahili at the Lutheran Hospital, Kiomboi, Tan- zania, Africa.

Dr. John Beeson (Alaska Medical License #20, 1916) who practiced in Anchorage many years as the chief surgeon of The Alaska Railroad, before moving to Ketchikan, is hale, hearty and retired in La Jolla at age 94. In 1933 Dr. Beeson moved to Wooster, Ohio and founded a medical clinic there, staffed originally with his two sons; Dr. Harold Beeson, a former Anchorage Times re- porter and now Assistant Medical Director for the Department of State in Washington, and Dr. Paul Beeson, now the Nuffield Professor of Medicine at Oxford University in England.

Dr. Henry Wilde, formerly of Juneau, is now regional health officer for the Foreign Service Diplomatic Corps in Guinea, Senegal and Maure- tania. Dr. Wilde is stationed in Conakry, Guinea.

With the advent of the new Republican admin- istration Dr. Levi Browning has been replaced as Commissioner of Health and Welfare by Dr. Wallace J. Chapman. Dr. Chapman was in general practice in Cordova for five years with his wife

ALASKA MEDICINE

Dr. Jean Chapman. He then worked for one year in California before returning to his present post in Alaska at Governor Hickel’s request. Dr. Browning is presently vacationing at his Palmer homestead. Also in Juneau Dr. Jack Lesh has been replaced by Dr. D. V. Reddy as Director of Mater- nal and Child Health and Crippled Children’s Services. Dr. Reddy is originally from Hyderabad, India. He trained in pediatric cardiology in Cleve- land and California, and got his M.P.H. in Cali- fornia. With his public health background, and as a board certified pediatrician and a board qualified pediatric cardiologist, Dr. Reddy has a rare combination of skills greatly needed in Alas- ka. In his new position as medical consultant for the Department of Welfare Dr. Lesh will have more time for his Gus Davis Inn project near Glacier Bay.

Dr. Grace Field has retired after many years as Clinical Director for the Veterans Administra- tion in Alaska. Her warmth and genuine interest will be missed. Dr. Field plans to live in Juneau. Her position has been filled by Dr. Richard D. Kraft of Virginia.

From Ketchikan we hear that Dr. Donald Wadsworth has moved to Bend, Oregon.

Dr. Donald Tatum recently returned to Fair- banks for four weeks, unfortunately as defendant in a malpractice suit Johnson vs Tatum. Dr. Tatum is a board certified internist who practiced seven years in Fairbanks. He now resides in Portland, Oregon where he specializes in allergy. Several weeks ago the jury brought in a verdict against Dr. Tatum of $300,000, which is twice the limit of his insurance liability (Lloyds). A brief summary of the case should be of interest to all Alaskan physicians. On June 30, 1962 Mr. Johnson, age approximately 50, was admitted to St. Jo- seph’s Hospital with a “stroke”. Past history, as obtained later, showed that he also had a possible transient stroke in 1960, a definite myocardial infarction before 1959, a history of some years of hypertension with recent return to normotensive levels on no medications, an elevated cholesterol (304) and a heavy smoking history. During his hospitalization Mr. Johnson was intermittently uncooperative, confused, and sedated. On about the eighth day in the hospital he developed leg pain which initially required Codeine every 12 hours but later required frequent doses of Dem- erol for control. Because of a discolored area on the leg anterolaterally and a tender thrombosed vein on the foot he was initially treated for phlebitis with heat cradle, hot packs, aces and

one pillow elevation. The patient apparently did not cooperate in keeping his aces and hot packs on. In any case he developed gangrene of the discolored area of leg and a toe, then his forefoot, and eventually went to the Mason Clinic for an above knee amputation. He apparently then re- turned to work in Fairbanks for over a year. Dr. Tatum was represented by Mr. Robert McNealy (retained by Lloyds). Mr. Johnson was represented by Mr. Savage of Anchorage, in cooperation with Mr. Parrish of Fairbanks. Mr. Leonard Schroeder of Seattle was again brought in on this case, as he is in so many of the medical malpractice oases on the west coast. He brought along two “expert” medical witnesses to Fairbanks, Dr. Robert Coe, a Seattle vascular surgeon, and Dr. Fisher, a Seattle internist. He also supplied the deposition of another “vascular expert” Dr. Abby Franklin, another Seattle internist. The claim of all these men was that the patient had an acute femoral bifurcation embolus and that he should have been sent immediately to Seattle for vascular surgery. Also that his embolus later must have moved down, since it obviously was not there when the leg was amputated. At amputation the femoral artery was found open. Also, even though at least two occlusions of the small vessels distal to the popliteal were demonstrated during an incom- plete examination of the specimen, that these occlusions were (1) probably embolic from the heart and (2) probably wouldn’t have caused trouble if heat had not been applied.

I had the privilege of two days on the stand in this case as an “expert vascular surgeon” and pointed out that all the limb vessels were severely- narrowed, that there was no evidence of any em- bolus, that embolism was rare even with a recent heart attack; and that no embolus large enough to completely block the femoral bifurcation would disappear down an anterior or posterior tibial artery narrowed by atheroma to a lumen of one or two millimeters. Also that although heat appli- cation was contra-indicated there was no evidence that the leg was not lost solely because of severe atherosclerosis with multiple occlusions. After the “experts” had thus finished contradicting each other the jury was left with a case in which hospital records were inadequate, several people claimed the defendant did serious wrong, and with a plaintiff sitting in the court room wearing a prosthesis he could barely control while walking in the court room.

Several important points are brought up by this case. (1) Mr. Schroeder in particular and other

z

MARCH 1967

plaintiffs lawyers generally have taken the trouble to learn more “almost medicine” than most defense attorneys apparently can or do. This makes sense, for after all if a lawyer is going to study enough medicine to impress a lay jury with his knowledge he might as well go where the chance for big money is, and it certainly is as plaintiffs attorney. (2) Contingency fees. The plaintiffs lawyers claim that these are essential to permit the poor man to sue when necessary, and that if the physician would just practice good medicine and “stop being a businessman” he wouldn’t get sued. Yet, while the plaintiffs lawyer takes Vs to V2 of these large judgments, after expenses are deducted, no one ever hears the physician say “If I cure you I want one-half of all the money you’ll ever make.” Should not the plaintiffs lawyer treat the poor as the doctor does, i.e., “Pay my regular fee, or a reduced fee if you can,” or even with Welfare support when avail- able? (3) Why are Alaskan physicians subjected to lawyers and medical “experts” from Seattle? We need a valid medical license to practice here, why should these men be permitted free access to us, when we have no comparable “specialist” lawyer available who does only medical liability defense work for the whole west coast.

Certainly if one searches long and far enough, one can get an “expert medical witness” who will

say anything one wishes, and may even be able to say it sincerely, either in ignorance or because it applies to his own ivory tower. Such men cannot understand, if they would, the problems of daily medical practice in Alaska, where each day one is called upon to care for something not quite “in his line” or specialty. If anyone has had previous legal encounter with Mr. Schroeder or especially with Dr. Coe, Dr. Fisher or Dr. Franklin as witnesses, we would be most interested in a brief summary of the circumstances. i4i With this type of decision and such judgment levels it is difficult to visualize the “plot” by the insurance companies that plain- tiffs attorneys so often blame all our problems on. Hopefully Dr. Tatum will successfully appeal this unbalanced decision, although the situation at present in Alaska appears weighted heavily against the physician. The present situation could well result in the plaintiffs attorneys “killing the goose,” as more physicians depart or become unable to get adequate insurance. Possibly these attorneys could then convince the public health service to expand and provide needed medical care. There should be no limit to the judgments they could get with the government as defendant.

LATE INFORMATION: Lloyds decided not to appeal and case against Doctor Tatum settled for 8150,000 plus costs.

j FOR THE LADIES ^

^ See Sitka at the Annual Convention in '67 j

»» **

\ 5

«»

s There will be something of interest for all — clam bake, sight-seeing, ; \ banquets, social hours, and business meetings. Come by car, ferry or ; J airplane — meet Miss Asher Yaguda, President of the Women’s Auxiliary ;

\ to the American Medical Association. \

PLAN NOW TO ATTEND I

\ \

13

ALASKA MEDICINE

THE REGIONAL MEDICAL PROGRAM FOR HEART, CANCER AND STROKE

By Donal Sparkman, M.D.

Dr. Donal Sparkman is Coordinator for the Regional Medical Program, Alaska-Washington region. He is currently based at the University of Washington Hospital in Seattle. Dr. Sparkman practiced internal medicine in Seattle for sixteen years. In 1959 he was appointed Clinical Professor of Medicine at the Uni- versity of Washington. From 1960 to 1966 he was State Medical Consultant for the Washington Division of Vocational Rehabilitation, and he assumed his present full time position, along with an Associate Professor- ship of Medicine, in March of 1966.

The first knowledge most of us had of the Regional Medical Program came with the report of the President’s Commission (DeBakey) on Heart, Cancer and Stroke mailed to all physicians in December, 1964. Of the thirty-five recommend- ations of the Commission those which received most attention were proposals for building new centers for research, training and patient care for heart disease, cancer and stroke. Though the DeBakey center concept was radically changed as the legislation to implement it passed through Congress, the image of the Regional Medical Program in the minds of most physicians was still that of a Federal medical program directing pa- tients to a University medical center with little concern for the role of the private physician or the community hospital.

It did not come out this way. Those who are skeptical of the impact on Congress of the indi- vidual physician should read the hearings of the Heart, Cancer, Stroke bill before the House Sub- committee. Distinguished physicians and those less well known, aroused by the implications of the Commission report, appeared in person before the House Subcommittee or otherwise communi- cated with their Congressmen. While many ex- pressed general approval of the bill, a number of witnesses questioned the need of such new centers and thought that any building should be preceded by a suitable period of planning. The Subcom- mittee was sufficiently impressed that they struck out the original bill and rewrote it incorporating many of the constructive recommendations of witnesses.

While the President’s Commission had recom- mended the development of many new centers, the new bill focused on the peripheral commun- ity; on a decentralization of teaching and of

patient care. The bill as it emerged has unusual features which make it attractive to the medical profession. It is not a Federal blueprint directing the way in which it shall be implemented. Rather it is brief, broad in concept and with considerable latitude as to its operation. It encourages local initiative in determining community needs and in planning to meet them; it stresses cooperative planning among physicians and others to make best available use of health resources in the region. There are no provisions for new construc- tion, no funds for patient care. There is to be no interference with the relationship of the prac- ticing physician with his patient, no alteration in administrative hospital practices.

Recognizing the potentialities of the legislation while it was still before Congress, Dean John Hogness of the University of Washington School of Medicine, began discussing it with officers of the Medical Associations of Washington, adjoin- ing states, and Alaska; with the governors of Washington and Alaska, and with Congressional representatives and leaders in voluntary health agencies. There was general approval of the bill as it emerged from Congress and shortly there- after Washington’s Governor Evans concurred in a recommendation that the University serve as the applicant for a planning grant. Governor Egan of Alaska, Dr. Royce Morgan of the Alaska Medical Association, and Dr. Levi Browning, Commissioner of Health and Welfare, among others were in agreement that Alaska join Wash- ington in forming a region for planning under t^he Heart, Cancer, Stroke bill, and this proposal was readily accepted by the Washington group.

A regional advisory committee was appointed from candidates offered by a broad representation of interested health organizations in the two states and included citizens appointed by the two governors. At its first meeting the Regional Advisory Committee recommended that the two states combine in a region under the Regional Medical Program. An application for this purpose was submitted to the National Institutes of Health in July, approved in September, 1966. The result- ing grant is for planning only and makes available funds for gathering data as to the existing re-

MARCH 1967

14

sources and needs in providing health care for heart disease, cancer and stroke in Washington and Alaska, as well as an appraisal of the existing programs and needs in continuing education.

Alaska representatives (Bruce Wright, Alaska Medical Association; Levi Browning, Alaska Com- missioner of Health and Welfare; Judge Thomas Stewart, Alaska Heart Association; and James Lanham, Alaska Cancer Society, have faithfully attended meetings of the Regional Advisory Com- mittee where they have vividly portrayed the unique as well as routine features of health care and continuing education in Alaska. Communica- tion between the two states regarding the Region- al Medical Program was enhanced by a visit of Dr. Lowell White, Associate Dean of the Univer- sity of Washington School of Medicine, to Anchor- age and Fairbanks in June, 1966, at which time he met with members of the Alaska Medical Associa- tion and the University of Alaska faculty. In December, 1966, at the invitation of Alaska repre- sentatives to the Regional Advisory Committee, Drs. Pat Lynch, Yakima Radiologist and a mem- ber of the Regional Advisory Committee, and Don Sparkman, Coordinator of the Regional Medical Program, visited Anchorage, Fairbanks, Ketchi- kan, Juneau and Sitka, meeting with members of the local medical society and others in the health professions at each location. In Juneau it was their privilege to discuss the Regional Medical Program with Governor Hickel, and in Fairbanks to meet with members of the faculty of the Uni- versity of Alaska.

Throughout their trip interest was evidenced in the RMP and in particular in the possibility of augmenting continuing education efforts for phy- sicians, nurses and technicians. In addition to the

possibility of scheduling more regular teaching visits by individuals and teams of experts, ques- tions were asked about the possibility of arrang- ing training sessions of one to four weeks duration for practicing physicians in fields of their choice in Seattle hospitals. The use of newer communi- cation devices such as video tapes, instant con- sultation, and single concept films were consid- ered as adjuncts to more conventional consulta- tion and teaching devices.

The trip served as an equally important learn- ing experience for the visitors who saw firsthand some of the unusual and often fascinating facets of life and the practice of medicine in the 49th State, not to mention its scenic splendors which exceeded expectation. Increased respect for the Alaska physician in both urban and rural areas was gained as the trip progressed.

While the distance between Alaska and Wash- ington presents special problems to the function- ing of the two-state area as a region within the Regional Medical Program, the eagerness of physicians in each state to improve communica- tions and relations between them plus the ad- vances in both transportation and communication makes this joint effort a reasonable possibility. In this time of rapidly expanding medical knowl- edge, with health care expectations exceeding our capacity to meet them, this program offers physicians an opportunity to plan ways in which they may better keep abreast of the rapidly changing medical scene and make best use of scarce health personnel and resources. Whatever benefits do develop in Alaska will be in response to Alaska physicians’ initiative and requests. Questions and comments should be directed to the Alaska State Medical Society, Committee on Heart, Cancer and Stroke.

15

ALASKA MEDICINE

PROFESSIONAL LIABILITY INSURANCE

By Rodman Wilson, M.D.

Dr. Rodman Wilson has practiced Internal Medicine in Anchorage for eight years and is presently chairman of the Anchorage Medical Society Legislative com- mittee. The following is an address delivered to the Anchorage Press Club on January 18, 1967.

What is malpractice? It is the dereliction of professional duty by a doctor or his assistant resulting in harm to a patient. The dereliction can be willful, criminal, or due to negligence, but since willful and criminal negligence are rare, one ordinarily implies negligence when speaking of malpractice by a physician. And since a phy- sician is human, he can and does make uninten- tional mistakes, often from being too busy or too tired, or from being preoccupied with other professional or even personal problems.

When negligence occurs or seems to occur, a patient will sometimes sue a doctor for the real or imagined damage done. One reason for believ- ing that an unfavorable outcome of a contact with a doctor has occurred comes from misunderstand- ing the nature of disease and the healing arts. We all read and hear about the wonderful accom- plishments of medical science, about “miracle” cures and amazing surgery. A patient under- standably may become disappointed, bewildered, and disgruntled when he too cannot have a miracle or an amazing recovery from his ailment. He may even be disappointed if his doctor does not behave in the grand image of the television doctor or old Dr. Gillespie. Patients often do not realize how much doctors do not know, and that cures for many conditions are not to be had any- where, not in Anchorage, in San Francisco, in New York, or London, or Stockholm. Further, some patients do not appear to know that many con- ditions worsen in their natural course. A patient may wrongly attribute the worsening to the treat- ment rather than to the disease, and feel that it is the doctor’s fault that he is worse. Some indi- viduals do not realize that they take a risk when- ever they step into a doctor’s office — a risk that the potent medicines and other forms of treatment today may harm them no matter how learned and careful the doctor prescribing them may be. When you take your flat tire to the garage, you can regularly expect that it will be satisfactorily fixed or replaced. Not so when you take your ailing heart to the doctor. Medicine is not that simple.

For protection from malpractice judgments arising from such lawsuits, a doctor buys profes- sional liability insurance. Rates for such insurance have been rising throughout the country in recent years, but have risen astronomically for many physicians in Alaska within the past year, osten- sibly because of a judgment against an Alaskan physician in which an untoward result following surgery was adjudged not to be due to negligence on the part of the doctor but was adjudged to be worthy of an award merely because a poor result had occurred. In other words a doctor has to get a good result, or risk being sued. This decision by the Alaska Supreme Court has apparently made many insurance companies unwilling to insure — at least at previous rates — Alaska physicians. Accordingly some physicians are presently with- out liability insurance, others are having to pay rates that they consider exorbitant for less cover- age than they had before, other physicians in relatively low-risk non-surgical practices continue to pay rates which have not changed appreciably, and in one instance, which seems rapacious to me, a physician was insured (for low coverage) only when he transferred his auto and home insurance from one Anchorage agency to another.

But the problem of professional liability ex- isted before the above cited case and seems largely to do with a prevailing attitude and mode of behavior in the United States which says that one should not bear the brunt and burden of his mis- fortunes in life. If he is burdened with aged, infirm parents, they should be placed in a nursing home at government expense so that his life will not be hindered by them. If his child is severely mentally retarded, it is the State’s job to assume care and costs, and if he himself is injured phy- sically, emotionally or otherwise, SOMEONE, certainly not he himself, is going to have to pay for it. I suppose that when the golden social millenium comes all misfortunes from cradle to grave will carry dollar awards. If these are automatic at least it will serve to eliminate all the troublesome, costly, painful litigation and will allow one to get on with the important, worth- while work of the world (if there be any left to do in the golden social millenium). But at the present, when one is hurt he seeks as hard as he can with as smart an advocate as he can find to capitalize on his misfortune — to be paid for his injury. Now

MARCH 1967

16

this is not just payment for his medical expenses but for his mental anguish (by the day and hour sometimes!, for his inconvenience, possibly for the temporary loss of enjoyment of his wife, and for all he might have earned if he had lived to a hale and hearty 65 or beyond; not considering, of course, that life always brings further vicissitudes which might alter the flow of money calculated so meticulously on court room blackboards. When he is successful in cashing in on his misfortune, he splits the award with the lawyer. This makes up, in part, for the cases the lawyer takes and loses, getting little or nothing.

My basic objection to this mode of behavior is that it is an unproductive, uncreative way of life and that it counsels a negative attitude toward one’s fellow man. It involves much loss of time on everyone’s part. It even hurts a doctor’s other patients, for there are few things which upset a physician more than to be sued. It shatters his confidence in himself and in a cherished way of life. Under these circumstances he can hardly be an effective doctor to his other patients, at least until the suit is settled.

I feel, then, that relief is needed someway or another from the threat and burden of large mal- practice suits. One element of relief would come with legislation which would require proof of negligence and place the onus of proof of negli- gence on the plaintiff. This would counteract the recent ruling of the State Supreme Court, in the opinion of some, and would put us back even with the other states, none of which has so unusual a precedent to my knowledge.

But more is needed to really come to grips with the problem. Alaskans, for a change, could lead the way to a solution, rather than to wait, as is so often the case, for leadership from some other i State. Suggestions advanced have been (1) com- ; pulsory arbitration of medical malpractice claims i before a committee of lawyers, physicians, and laymen (2) mandatory expert testimony to the : court (3) statutory limitation of awards for losses (4 1 abolition of contingency fees in malpractice cases (5) a State system of professional liability insurance which could cover other professions such as dentistry, insurance, accounting, and law.

I strongly advocate some such legislative relief. It is sorely needed to continue to make the practice of medicine attractive in Alaska. A doctor must be able to express himself professionally without fear of personal economic disaster from a lawsuit. Doctors, even now, who are planning to settle in Alaska are being advised not to do so until the climate is more favorable in these matters.

If relief is not obtained, some doctors may leave, others will not come, and even more impor- tantly, there is a significant danger of stultifying medicine by producing a breed of pusillanimous milque-toast physicians who are afraid to take bold, imaginative, highly tailored, highly specific courses of management for their patients, for fear of being sued because the approach was not usual or orthodox. In the long run orthodoxy and standardization breed mediocrity and eventually make a system anemic and lifeless. I for one do not want this for medicine, and I do not believe that you do either.

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ALASKA MEDICINE

PROPOSED MEDICAL LIABILITY ACT

With Cover Letter

February 8, 1967

The Honorable Walter J. Hickel, Governor State of Alaska

State Capitol — Juneau, Alaska Dear Governor Hickel:

Enclosed is a copy of a bill which has been drafted at the request of the Alaska Medical Association, The purpose of the bill is to clarify a situation which has arisen as a result of a 1964 Supreme Court decision. The decision that we are referring to is the case of Patrick vs. Sedwick.

That decision has clouded the air with respect to the burden of proof in cases wherein physicians are sued for malpractice. The decision appears to put the burden of proving innocence on the part of the defending physician in such cases. While we cannot be certain that the Supreme Court of Alaska intended that to be the result of its decision, the fact is, however, that insurance companies throughout the nation which offer malpractice coverage have interpreted the deci- sion to mean that the case law in Alaska now requires the defending physician in a malpractice case to prove his innocence. As a result of this, a number of insur- ance companies have withdrawn from the field of offering malpractice coverage to Alaska physicians. In addition, the rates of the few companies still offer- ing coverage to Alaska physicians have increased to the point where many physicians find the cost of malpractice coverage to be prohibitive.

The uncertainty created by the impact of this decision on those in the business of offering insurance is working to the detriment not only of Alaskan phy- sicians but also to the detriment of the citizenry of Alaska who are indirectly benefited through the availability of such coverage. It is important that the law be clarified. The copy of the bill that we have submitted to you is designed to remove the uncertainty as to the procedure the courts will apply in medical malpractice cases and to clearly establish the rule that the plaintiff-patient bringing an action against his physician must prove his case by a preponderance of the evidence. The rule applies in all civil cases, and this bill is designed to make it clear that the same rule should apply in civil malpractice cases.

It is probably not likely that the Alaska Supreme Court meant to upset this well established rule of pro- cedure; but unfortunately until another case reaches the Alaska Supreme Court, the situation in Alaska with reference to suits against doctors for malpractice is up in the air. That being the case, malpractice cover- age has become unavailable to a number of Alaska physicians. This bill clarifies the law without waiting for the Alaska Supreme Court to bring forth another decision. This latter could take years since the court has no control over what cases are brought before it. The situation as it presently exists in Alaska has caused physicians contemplating practice in Alaska to change their minds about coming here at all. Alaska needs physicians. The shortage that exists already will be- come more severe. This is not simply theory on the part of Alaska physicians. We have had letters and comments from outside doctors who have changed their minds about practicing in Alaska because of the uncertainty of the legal situation. A number of Alaska doctors are so concerned about these uncertainties that they are contemplating establishing practice elsewhere.

The bill we have drafted is not a special interest bill. It provides only that the plaintiff bear the burden of proof in malpractice suits against doctors .just as the plaintiff must do in every other case wherein he files suit. We are not asking any privileges that are not accorded to every other citizen of the state when and if he should be sued in a court of law.

Sincerely,

Alaska State Medical Association

AN ACT

Relaling to medical malpractice actions in Alaska based on negligence; setting the standards of knowledge and skill required of physicians practicing in Alaska; and establishing the burden of proof in such cases.

Be it enacted by the Legislature of the State of Alaska:

In any malpractice action based on negligence against a physician licensed under this Chapter, the plaintiff will have the burden of proving:

(1) That the defendant physician either lacked the skill or knowledge, or failed to exercise the degree of care, commonly possessed or exercised by other physicians in the same specialty in the community where such de- fendant practices; and

(2) That the plaintiff suffered injuries that would not otherwise have been incurred as a proxi- mate result of such lack of knowledge, or failure to exercise such skill.

In each case the plaintiff will have the burden of proving by expert medical testimony (1) the degree of knowledge possessed, or the degree of care ordinarily exercised, by physicians of the same specialty practicing in the community where the defendant practices; and (2) that the defend- ant failed to possess such knowledge, or failed to exercise such degree of care, in the particular case.

In no case at law may negligence on the part of a physician or surgeon be presumed; it must be affirmatively proved.

The jury shall be instructed that in cases where diagnosis or treatment, or both, involve risks of injury or disability to the patient, the patient has the burden of proving by a preponder- ance of the evidence that the injury or disability alleged to have been suffered by him came about as the result of negligence on the part of the physician and the jury shall be further instructed that the fact of injury or disability alone is not proof of negligence on the part of a physician.

In trials to the court sitting without a jury, the same principle shall be applied by the court.

MARCH

1 967

18

LEGISLATIVE ABSTRACTS

The following bills of interest to the medical

community have been introduced into the Alaska

Legislature for consideration.

SENATE BILLS

S.J.R. 2: Christiansen and Blodgett: “Relating to the establishment of a hospital at St. Mary’s and Unalakleet.” Referred to the HEW. 1 30 67 S.B. 10: Ziegler: “An Act requiring that drivers license show that licensee’s blood type; and providing for an effective date.” Referred to State Affairs and Finance Committee. 1/23/67

S. B. 40: Bradshaw: “An Act relating to the Board of Nursing and its executive officer.” Referred to HEW Committee. 1 30 67 S.B. 53: Thomas, Smith, Palmer, Koslosky, Brad- shaw, Begich, Brady and Harris: “An Act relating to licensure of psychologists; and providing for an effective date. Referred to HEW and Judiciary Committees. 2 2 67 S.B. 55: Begich and B. Phillips: “An Act requiring continuing education of dentists.” Referred to HEW Committee. 2 2, 67 S.B. 62: B. Phillips, Harris and Brady: “An Act relating to licensing of dentists; and provid- ing for an effective date.” Referred to HEW. 2 3/67

S.B. 70: Brady: “An Act relating to the Uniform Narcotic Drug Act.” Referred to HEW Com- mittee. 2/6/67

S.B. 79: B. PHILLIPS: “AN ACT RELATING TO MALPRACTICE ACTIONS.” REFERRED TO HEW AND JUDICIARY COMMITTEES. 2/8/67. THIS BILL WAS LATER (AP- PROXIMATELY FEBRUARY 14, 1967)

WITHDRAWN BY MR. PHILLIPS.

S.B. 80: Haggland and Ziegler: “An Act relating to the formation of professional corporations; exempting professional corporations from the provisions of the Alaska Employment Security Act; and providing for an effective date.” Referred to Commerce and Judiciary Committees. 2/8/67

S.B. 89: Rules Committee by request of Governor:

“An Act relating to civil liability for render- ing emergency aid to accident victims; and providing for an effective date.” Referred to the Judiciary Committee 2/10/67 S.B. 93: Palmer and B. Phillips: “An Act providing for the prevention of air pollution.” Referred to HEW Committee. 2/10 67

HOUSE BILLS

H.J.R. 2: By a host of Representatives: “Relating to the establishment of a hospital at Andreaf- sky.” Referred to the State Affairs Com- mittee.

H.J.R. 4: Hohman: “Relating to the funding of the Bethel pre-maternal and foster care homes.” Referred to the State Affairs and HEW Committees. 1/31/67 Passed House of Representatives 2/9/67.

H.C.R. 7: Fritz: “Relating to the use of Alaska Medical and allied health facilities.” This resolution concerns itself with urging the use of medi- cal specialties and facilities which are avail- able in Alaska. Passed the House of Repre- sentatives 2 3/67.

H.C.R. 9: Fritz: Relating to the need for facilities for the disposal of human waste.” Referred to Local Government and HEW Committees. 1/31/67

H.J.R. 17: “Relating to support for the implementation of Public Law 89-749.” Referred to the HEW' and Finance Committees. 2/9/67 H.C.R. 19: Fritz: “Relating to vision and hearing equip- ment at the Pioneers Home.” Referred to the State Affairs and Finance Committees. 2 8 67

H.C.R. 20: Fritz: “Relating to health personnel at the Pioneers Home.” Referred to the State Af- fairs and Finance Committees. 2/8/67 H.B. 22: Ray: “An Act relating to the giving of aid to victims of emergencies.” Referred to HEW and Judiciary Committees. 1/23/67 H.B. 31: Fink, Borer, Beirne, Fritz and Orbeck: “An Act relating to drivers’ licenses, and pro- viding for an effective date.” Requires blood type be shown on license and applicant’s personal physician listed. Referred to State Affairs Committee. 1/23/67 H.B. 68: Fritz: “An Act relating to eyeglasses and sunglasses.” Referred to Commerce Com- mittee. 1 '27/67

H.B. 73: Fritz, Beirne and Bradner: “An Act relating to the disease Phenylketonuria; and provid- ing for an effective date.” Referred to the HEW and Finance Committees. 1/31/67 H.B. 74: Fritz: “An Act appropriating to the Depart- ment of Health and Welfare; and providing for an effective date.” Provides for an ap- propriation of $10,000 for the cost of per- sonnel and testing materials described in H.B. 73. Referred to HEW and Finance Com- mittees. 1/31/67

H.B. 90: HEW Committee: “An Act relating to the Board of Nursing and its executive officer.” Referred to Commerce and HEW Commit- tees. 1/31/67

H.B. 115: Moses and Ray: “An Act relating to the giving of aid to persons in need of medical care and assistance.” Referred to HEW and Judiciary Committees. 2/3/67 H.B. 127: BEIRNE: “AN ACT RELATING TO MEDI- CAL MALPRACTICE ACTIONS.” REFER- RED TO HEW AND JUDICIARY COM- MITTEES. 2/6/67

H.B. 130: Beirne and Fritz: “An Act relating to the licensing of Physical Therapists.” Referred to Commerce and Finance Committees. 2/7/67

H.B. 131: Beirne: “An Act relating to the time a child must be abandoned before an order termin- ating parental rights is entered and provid- ing for an effective date.” Referred to HEW and Judiciary Committees. 2/7/67 H.B. 132: Beirne: “An Act relating to the membership of the State Medical Board.” Referred to Commerce and HEW Committees 2/7/67 H.B. 178: Beirne: “An Act relating to chemical analy- sis of blood in prosecution for driving under the influence of intoxicating liquor.” Refer- red to the Judiciary Committee. 2/14/67 H.B. 179: Beirne: “An Act relating to implied consent to chemical tests as to alcohol content of blood.” Referred to State Affairs and Judi- ciary Committees. 2/14^67

19

ALASKA MEDICINE

EXTENSUALiS OBSTETRICUS

— A Fable —

Anonymous

Once upon a time there was a good, intelligent, conscientious physician named Smith-Jones, who practiced in a far-off country called Aksala. He loved his country, his patients, and his trust- worthy friends. He had a patient named Mrs. Brown, who had had two pregnancies, one ending at six weeks and one at three months in spontan- eous abortion. He had another patient with iden- tical difficulties named Mrs. Smythe. Because he was a good and knowledgeable physician who loved people and babies, he treated both Mrs. Brown and Mrs. Smythe with thyroid. Proges- terone and maybe a little dab of Marezine and per- haps some vitamins; and allowed his nurse to do routine urine checks in his small laboratory.

Now it came to pass that Mrs. Brown had a Fine Baby Boy and was exceeding glad and rejoiced. And one week later, Mrs. Smythe had a Fine Baby Girl and was exceeding glad and rejoiced.

But —

One year later it became plain for all to see that Mrs. Smythe’s baby was inferior, and had crossed eyes, and cried occasionally, and exhibited deficiencies in her reflexes.

Dr. Smith-Jones assured Mrs. Smythe that her pre-natal care had been good and conscientious and, in fact, identical with that of Mrs. Brown, and that her daughter’s condition wasn’t unex- pected since Mrs. Smythe and her brother and his sister and her mother also had crossed eyes and deficient reflexes.

But —

Mrs. Smythe read the newspaper, and THYME and NEWMONTH and that indisputable medical journal, LOOKER’S DIGEST; she also had a phar- macist friend who read all the releases from the FDA (Fraternal Drug Advisors). They both had friends who were S.J.’s, which, in this country, means Seekers of Justice. The S.J.’s found that the FDA had listed Thyroid, Progesterone, and Marezine as dangerous drugs since, in excessive

doses, they could cause deformed babies in a very rare breed of Australian Platypi. The FDA alsc found that large doses of caffeine could cause deformed babies in guinea pigs. Therefore, they concluded that Dr. Smith-Jones had erred grev- iously in using these drugs to assist Mrs. Smythe in producing a full-term baby and Mrs. Brown tc have a Bouncing Baby Boy. The S.J.’s also decided that Dr. Smith-Jones should have interdicted coffee even though millions of pregnant women had had their morning coffee (Indeed, their mid- morning coffee, their noon coffee, their early afternoon coffee, their mid-afternoon coffee, their late afternoon coffee, their dinner coffee, and their evening coffee) without apparent influence on their issue.

And so it came to pass that Dr. Smith-Jones was relieved of his practice, his home, his auto, and his expensive cigar lighter (and in the process, his admittedly rather flighty young wife) because a jury of his pee-rs decided that he had adminis- tered dangerous drugs, and because he hadn’t requested a 19 Keto-synergy-B-S-orthodiabolic acid test which would have determined the pres- ence of the cross-eyed genesi (He didn’t know about the test because it had only been described six weeks after the babies were born, in THYME magazine.)

Whereupon, Dr. Smith-Jones resigned from the practice of medicine in Aksala, and betook himself to a place called Bathing Ton, and after taking a 5-year course in stagnation and bigotry, he quali- fied for an eminent position with the Fraternal Drug Advisors Bureau.

P. S. — Careful investigation revealed that Mrs. Brown had three more Bouncing Baby Boys, and Mrs. Smythe had three more cross-eyed, reflexless daughters.

Anoiiymous

From ENCYCLOPAEDIA UNIVERSALIS, Year 2556 “History of Ancient Medical Practice; Fables of the Tyme,” pp. 1637-1966.

MARCH 1967

20

LIVER SCANNING

By Bruce Wright, M.D.

It is well known among radiologists that esti- mation of liver size radiographically can be grossly erroneous. Special studies such as spleno- portography and celiac axis angiography can be used to evaluate the liver. These procedures are difficult to perform, expensive, time consuming, and not without possible patient hazard. The radioisotope liver scan is a safer, less expensive, more easily performed, and more easily inter- preted study, providing a high degree of reli- ability. The hepatic scan provides a visual image of the liver as a functioning organ, especially regarding size, shape, and presence of space occupying masses. Among the several radioisotope compounds currently in popular use for “map- ping” the liver, the Department of Radiology at Providence Hospital utilizes Colloidal Gold 198 (Va life 2.8 days). Tiny particles of colloidal gold are phagocytosed by the reticuloendothelial cells. The fact that the radioactive gold remains in the cells for a period of time permits patients to be re-scanned on subsequent days. It is possible to obtain adequate scans in the presence of paren- chymal disease or with a severely jaundiced patient.

Following an intravenous dose of colloidal | gold, approximately 80% is cleared by the Kupffer cells. Clearance is practically complete within 30 . minutes. As this material is cleared by the | reticuloendothelial system, uptake is not depend- j ent upon hepatic parenchymal function, but is dependent in general upon liver blood flow and ' the integrity of the Kupffer cells. Since the sub- ! stance is not handled by the parenchymal cells, i an accurate estimation of liver function is not possible. However, since liver disease almost always affects both parenchymal and reticulo- endothelial compartments, the colloidal material actually is useful in gauging liver function, except in judging obstruction to the biliary tree.

The most important clinical aspect of hepatic scanning is the demonstration of space occupying masses within or adjacent to the liver. The liver scan has been shown to be useful for detecting primary carcinoma of the liver, hydatid cysts, liver abscesses, and extra-hepatic tumor. It is also of value in patients undergoing therapy wherein serial scans of the liver can be obtained to observe the effects of chemotherapy, radiation, or surgery.

Clinical determinations are often inadequate

(1.) Normal Liver

21

ALASKA MEDICINE

in excluding metastatic disease and a liver scan may be extremely helpful, even before the liver enlarges or chemical changes occur. Photoscan localization of large metastatic deposits are help- ful in liver biopsy. Depending upon the depth of the lesion and the area, the smallest lesions that can be detected run about 3 cm. in diameter. The liver scan can be superimposed on a survey film of the abdomen taken at a six foot distance. This is useful for describing subphrenic abscesses or in ruling out these lesions when liver can be seen to clearly occupy all the area beneath the right hemidiaphragm. Shown in the accompanying pic- tures are: il' a normal liver; i2) metastatic disease in the liver; this pattern of multiple discrete defects may also be seen in multiple abscesses, hematomata and rarely in cirrhosis; '3' shows a cirrhotic scan; this patchy decrease in uptake may also be seen in biliary cirrhosis, hepatitis, or diffuse infiltrative metastatic disease; i4i demon- strates a single large central liver abscess. This pattern is also seen in hydatid disease, hepatoma, or huge solitary metastatic lesion.

(2.) Metastatic Disease

(3). Cirrhotic Scan

(4.) Central Liver Abscess

SUMMARY

Radioisotope scanning of the liver at present represents the safest, simplest, and most effective method of depicting the size, shape, position, and appearance of the liver. 85' < to 90' < reliability of interpretation can be achieved.

MARCH 1967

22

TENTH ANNUAL LEDERLE SYMPOSIUM FOR ANCHORAGE

A decade of annual post-graduate sessions for Alaska physicians was observed on February 25, 1967, when the tenth annual medical symposium sponsored by the Anchorage Medical Society and Alaska Chapter of the American Academy of General Practice was conducted at the Anchorage- Westward Hotel.

Made possible by a grant from Lederle Labora- tories, the Anchorage symposia have attracted a total attendance of 938 physicians from through- out the state.

Gerald Egelston, manager of educational serv- ices for Lederle Laboratories, reported that An- chorage, because of its size and location, is the only city in the nation in which the symposiums have been repeated for ten successive years. Attendance is acceptable for six hours of continu- ation study credit by the American Academy of General Practice.

The first five Anchorage meetings were desig- nated as “post graduate seminars with round- table discussions.” Since 1963, each of the annual meetings has been identified as a “Symposium.”

Program chairman for the first post-graduate session in 1958 was Dr. George Hale. Medical educators traveling to Alaska for the initial meeting were Dr. Charles Bailey, Professor of Thoracic Surgery at Hahnemann Medical Center, Philadelphia; Dr. Fred M. Taylor, Associate Pro- fessor of Pediatrics, Baylor University College of Medicine, Houston; Dr. Walter S. Priest, Associ- ate Professor of Medicine, Northwestern Univer- sity Medical School, Chicago, and former presi- dent of the American Heart Association.

Moderators for the pioneering session were Anchorage Doctors Francis J. Phillips, John C. Tower and Robert B. Wilkins. Attendance at the first session was 77 physicians.

Program chairman for the 1967 symposium was Dr. Frederick J. Hillman. Visiting speakers were Dr. Matthew Block, Professor of Medicine and Chief, Hematology Division, University of Colorado Medical Center; Dr. Rene B. K. Menguy, Professor and Chairman, Department of Surgery, University of Chicago Medical School, and Dr. Martin M. Hoffman, Associate Professor of Medi- cine, McGill University Faculty of Medicine, Montreal. Moderators for the tenth symposium were Doctors Frederick R. Hood and Winthrop Fish.

As an outgrowth of this year’s session. Doctor i Hoffman rearranged his return schedule to stop off at Ketchikan, where he delivered his Anchor- age papers to the medical staff of Ketchikan General Hospital on the evening of February 26 and morning of February 27.

In prevailing on Doctor Hoffman to stop off at Ketchikan, Dr. Arthur Wilson pointed out that the First City is nearly 1200 miles from Anchor- age, and it requires a full day coming and going to attend the Anchorage meeting. The Ketchikan stop-over for Dr. Hoffman was sponsored by the Alaska Chapter of the American Academy of General Practice.

Since the first Lederle-supported symposium was held in Knoxville, Tennessee in 1952, more than 135,000 physicians have attended more than 500 symposia in more than 200 different cities in the 50 states.

Mr. Gerald Egelston, manager of education serv- ices for Lederle Laboratories, who has assisted with each of the ten symposiums conducted in Anchorage. For his work, Mr. Egelston was recently awarded honorary membership in the Anchorage Medical Society, first non-physician so honored.

23

ALASKA MEDICINE

A colonel in the Pacific Theater in World War 11, Mr. Egelston and his four-member staff work up to 16 months ahead in planning the symposia. More than 760 medical specialists have appeared on the programs, reporting on a wide range of medical and surgical techniques, development and problems.

For his decade of work in Anchorage, Mr. Egelston was presented a certificate of honorary membership in the Anchorage Medical Society on February 25, the first non-physician so honored. He had previously been given special recognition by the California and Kentucky Academies of General Practice, the American Medical Women’s

Association and the Peoria County ( Illinois i Medical Society.

As a special tribute to Alaska’s Centennial year and its tenth successful symposium, Dr. Benjamin W. Carey, Medical Director of Lederle Laboratories Division of American Cyanamid Co., directed that more than 100 pounds of vitamins and anti-biotics be presented to St. Mary’s Mission on the lower Yukon River. The Mission had reported its supply of vitamins was almost exhausted.

The special gift was presented by Mr. Egelston on February 23 to Rev. Rene Astruc, S.J., Jesuit Superior of St. Mary’s.

• (

This slide was the first one shown at a medical meeting in Alaska after it became a state. It was flashed on the screen at the symposium on Anchor- age on Feb. 21, 1959. Target for the young state is

Texas.

MARCH 1967

24

PERIPHERAL VASCULAR SURGERY IN REVIEW

By Arndt von Hippel, M.D.

V

9

1

Having attended medical school during the slow breech delivery of modern vascular surgery, I was taught much decriptive material that was soon outdated. Over the past ten years, with improvements in materials and techniques, we have progressed from repairs through simple but risky replacements to generally satisfactory major vascular reconstructions. 1 have been im- pressed during this time with the relative ease of acquiring technical know how and proficiency, compared with the difficulty in developing a coherent approach to vascular problems. The following is one man’s approach to peripheral vascular surgery, minus most of the “magic word” and “knock the wood” factors. I hesitate to expose it in its simplicity after so many years in its pursuit.

An accurate diagnosis of acute arterial or venous occlusion can usually be made from the manner of onset and the changes noted in the involved area. Let us consider first the legs. A sudden onset of pain, numbness, tingling, pallor, and coolness suggests an arterial obstruction. A more gradual onset of pain with aching and swelling is typically venous. Major swelling means venous and not arterial obstruction regard- less of whether the leg is purple, blue, mottled, or white, and regardless of the peripheral pulse.

Often in an ischemic limb of borderline viabil- ity the patient is unable to wiggle his toes. Veins on the ischemic foot are flat and almost trans- parent. With major venous occlusion the super- ficial veins on the thigh and often even the lower abdomen are abnormally prominent.

ILEOFEMORAL THROMBOPHLEBITIS

When the swelling extends to the inguinal area • and it is not due to infection, injury, or tumor) the diagnosis is “ileofemoral thrombophlebitis.” At this stage the clot is well up the iliac vein and often extends into the vena cava.

An acute ileofemoral thrombophlebitis can properly be treated by surgery and/or heparini- zation. Selection of treatment depends upon the duration and progress of the thrombosis, and upon the facilities and skill available. A venous throm- bectomy performed by the self-taught and occa- sional vascular surgeon is more dangerous than medical treatment.

Venous Thrombectomy

If the leg is acutely swollen and the patient ill, and if the disease appears to be progressing, thrombectomy should be considered. This pro- cedure is performed under local anesthesia to permit patient cooperation. A Valsalva maneuver; is helpful during the evacuation of clot from the: inferior vena cava. At least four units of bloodi should be available for immediate use. When properly performed through a femoral vein inci- sion, clot can be extracted all the way from the; vena cava down to the ankle veins with little risk: of pulmonary embolus. The clinical response to i thrombectomy is dramatic, as the toxic and often semi-stuporous patient rapidly becomes alert and i cheerful. The leg usually approaches normal size^ within twenty-four hours. The general toxicity seen with this condition is probably due to the massive sequestration of extracellular fluid in tne leg.

Thrombectomy appears to be followed by little or no venous disability. Venous ligation concur- rent with thrombectomy is unnecessary and unde- sirable, whether saphenous, femoral, or caval, as it leaves a stagnant venous bed ripe for more complications. Relative contraindications to thrombectomy include a self-limited phlebitis or one which has started to improve, and an almost absolute contraindication is a patient to whom heparin cannot be given, as heparin is necessary for successful thrombectomy. Strict bed rest, a well padded foot board, elevation of the legs, and vigorous heparinization should be part of any therapy for ileofemoral thrombophlebitis unless anticoagulants are contraindicated. Vena caval ligation should be reserved for the patient who cannot tolerate anticoagulation, or who has recur- rent pulmonary emboli while well anticoagulated, or septic phlebitis. When emergency thrombec- tomy is performed I like to give the initial heparin dose directly into the femoral artery. Hopefully this gives the maximal effect where needed most.

HEPARIN THERAPY

A word on heparin therapy. This is far prefer able to the coumadin type of anticoagulant In the treatment of acute thrombotic processes. I might say here that heparin therapy within several days after arterial surgery is dangerous and rarely

25

ALASKA MEDICINE

indicated (see discussion below). I have found the following heparin regimen effective. After a control Lee-White clotting time, aqueous heparin (usual dose range 50-100 mg., 5,000 to 10,000 units) is given deep subcutaneously every six hours. To avoid distressing hematoma formation a sharp disposable long 23 or 24 needle should be used. The needle should not be burred by previous puncture of a rubber vial top. To assure adequate rotation of puncture sites many prefer to draw a target grid on the skin of the abdomen, thigh, or flanks.

The aim of this heparin regimen is to elevate the five hour venous clotting time (drawn five hours after the last dose) to about 15-20 minutes. The heparin dosage has to be carefully regulated. Even after stabilization a daily clotting time is done. The heparin consumption often seems to decrease as the thrombotic process subsides, and cumulative effects are common.

AMBULATION

Following venous thrombectomy and/or bed rest and heparinization the patient is not ambu- lated until the leg is asymptomatic and minimally tender. Then a progressive ambulation schedule is started while fully heparinized until the patient can walk without symptoms. Should long :erm anticoagulation be planned, an adequate suppres- sion of prothrombin time must precede the dis- continuation of heparin. We have kept most of these patients on Coumadin for 3-6 months when there was no contraindication.

ACUTE ARTERIAL INSUFFICIENCY

On the arterial side one must decide whether to fish for clot, or cut ganglia, or anticoagulate. Emergency sympathectomy has not worked out well. External heat or elevation of the leg should not be used, as heat will increase the metabolic demand for blood while elevation will further decrease the perfusion pressure. We are left with a horizontal patient either in surgery or in bed. In either situation dehydration must be avoided.

When balancing emergency arterial surgery against anticoagulants one is more tempted to do surgery if the patient is young, and has healthy vessels, if the occlusion is most likely embolic, if the vessel block is proximal, and if the occlusion was recent within hours. Pushing one toward anticoagulation would be a generally arterio- sclerotic patient, possibly with hard femoral vessels and missing pedal pulses on the opposite leg. Also against emergency surgery is a distal

level of occlusion, say below the popliteal, a stable ischemic situation, or a leg which is practically demarcated, compromised, or useless.

There are practical reasons for these rules. Most occlusions by far are arteriosclerotic and not embolic. Many acute occlusions improve spon- taneously as collaterals open and enlarge. Many, perhaps most, occlusions are gradual and almost silent. The frequency of major vessel occlusions with minimal symptoms has been one of the more striking findings coming from the routine use of aortography in the evaluation of chronic circu- latory problems. Arteriosclerotic vessels tend to develop useful collaterals unless they close very rapidly. Effective collateral vessels are usually not available in the younger population.

An acute arterial occlusion at a distal level, say popliteal or beyond, is unlikely to benefit from emergency arteriography or surgery unless (1) very recent (2) embolic, and (3) located m a relatively healthy vessel. An exception here is a ruptured popliteal (or femoral) aneurysm, which is always a surgical emergency if the limb is to be preserved. These aneurysmal vessels are differ- ent anyhow (see below). The more proximal the occlusion the more successful the surgery. This holds true even for patients with arteriosclerosis. Here also, indications for emergency surgery are limited however. No one would electively defer surgery on an aortic or iliac artery embolus. On the other hand, the occasionally seen massive aortic thrombosis cannot be treated in any fashion.

Angiography or surgical intervention in the barely viable limb during the acute phase can be the last straw. Most elderly patients with acutely symptomatic occlusions that any treatment could help, will improve on bed rest and heparin therapy. After collateral has had a week or tv/o to develop, aortography and surgery will more likely be well tolerated.

TRAUMATIC ARTERIAL OCCLUSION

The acute major artery occlusion in the young is generally post-traumatic or embolic, and re- quires emergency surgery. Traumatic arterial occlusion can be due to sharp or blunt injury. The sharp injury is usually more obvious although there may not be massive bleeding. Apparently minor blunt trauma may lead to occlusion, as in one case where a teen age boy walked into the tail fin of an automobile, bumping his femoral area.

I have often heard of post-traumatic spasm

MARCH 1967

26

leading to a complete loss of local and distal pulses, but I have never seen this. I believe that almost any injury resulting in a loss of distal pulses warrants early exploration. Findings at surgery are almost always the same. The injured vessel feels clotted but the lumen occlusion turns out to be secondary to a subintimal hematoma. A progressive intraluminal thrombosis can follow. As mentioned previously, heparin therapy after arterial surgery is dangerous and almost never indicated. This is because bleeding is much more likely than thrombosis after a reasonably satis- factory reconstruction. No experienced vascular surgeon would knowingly even consider a patient with thrombocytopenia or other bleeding tenden- cies for arterial reconstruction, because normal clotting is essential to arterial surgery.

LEVEL OF ARTERIAL OCCLUSION

To help ascertain the level of arterial occlusion in an acute episode it is helpful to know what pulses were previously present. Lacking this in- formation one may have to guess, using the opposite limb for comparison. The ischemic level is always distal to the level of occlusion, as nutri- tion at any level is delivered by small arteries derived from more proximal major branches. It is helpful to remember that emboli usually stick in narrowed areas such as the aorto-iliac bifurca- tion. Surgically significant atheromatous disease is also most common at these sites.

Prior to operation on any diseased vessel it is important to know if other vessels in the area are involved. For this reason I do trans-lumbar aortography preoperatively on all patients w<th chronic vascular insufficiency of the legs. It turns out that a symptomatic arteriosclerotic occlusion of the femoral artery is almost always associated with marked aorto-iliac occlusive disease. In fact a chronic arteriosclerotic femoral occlusion usu- ally does not get symptomatic unless there is also proximal obstruction. This can be demonstrated by surgical correction of the aorto-iliac disease only, which results in the patient becoming asymptomatic. Aorto-iliac surgery has become my usual approach to a patient with both aorto-iliac and femoral arteriosclerotic occlusions.

Some schools however do mostly femoral arteriograms. It is true that one can frequently relieve symptoms in patients with femoral occlu- sive disease by bypassing much of the femoral artery, preferably by use of a long saphenous vein bypass graft. But even with saphenous vein grafts the failure rate is higher than after aorto- iliac surgery.

All arterial bypass operations have the same disadvantage when compared with accurate reconstruction (endarterectomy). That is they deliver a relatively high volume flow past a diseased vessel. This results in a reduced pressure gradient along the old artery. The smaller capac- ity line in such a parallel circuit, that is the arteriosclerotic trunk and its collaterals, then will tend to close and thrombose. Consider also that small vessels with low flows and long channels clot more easily, and remember that any incision on an ischemic limb will cut some functioning blood vessels. One can now see the advantage of a procedure which will deliver blood at a higher pressure to the entire vascular bed. One can also see why thrombosis of a bypass graft in the thigh can result in a situation more ischemic than before surgery, or even limb loss. The better long term results seen with an attack on the most proximal significant occlusion can therefore be explained.

TRANSLUMBAR SYMPATHECTOMY has

been alternately overapplied and maligned. Prior sympathectomy appears to protect a limb from critical spasm during an acute episode of vascular occlusion. Sympathectomy is frequently com- bined with aortoiliac surgery and adds little to operating time or risk. I feel that translumbar sympathectomy by itself has been useful in the management of some patients with chronic vas- cular insufficiency when vascular surgery was not feasible.

There are many ischemic limb situations in which vascular surgery has little to offer. If angina is severe, intermittent claudification may not be a bad way to limit activities. When a limb is of no use, or when associated conditions will limit surgery or recovery, vascular surgery should not be encouraged.

RENAL VASCULAR HYPERTENSION

No discussion of abdominal aortography for vascular disease is complete without a mention of the renal arteries. When hypertension presents in the first four decades, or is progressive and severe, evaluation of the renal arteries by aortography should be considered. This of course is particularly true if the patient is felt to be a candidate for surgical intervention. The most sophisticated and modern renal function tests can only suggest renal artery narrowing. A final decision on arterial pathology and surgical treat- ment can only be made after aortography. An IVP before aortography is often worthwhile for renal

27

ALASKA MEDICINE

evaluation. If desired however, one can obtain a good IVP on films taken just after translumbar or retrograde aortography.

The best results with surgery for renal artery hypertension are seen in conditions such as proxi- mal artery fibromuscular hyperplasia in the younger patient. On the other hand the older patients with renal arteriosclerotic occlusive di- sease tend to have a poor prognosis with or without renal artery surgery. In fact there is a tendency to shy away from renal artery surgery in the elderly in centers where this was formerly promoted.

CAROTID ARTERY SURGERY

Reconstruction of carotid and ventebral vessels is now possible, but the indications are not yet completely clear. It is generally agreed that the patient with multiple small or transient strokes should be evaluated for surgery. Also it now appears that the patient with a severe and pro- gressing stroke is in a high risk category with or without surgery, although even here excellent results can occasionally be obtained. Generally the extreme variability of clinical course seen in different stroke patients makes one hesitate to recommend routine angiographic evaluation for carotid surgery in the elderly stroke patient. Interestingly enough angiographic localization of the lesion has somewhat discredited the diagnostic accuracy of the neurological examination.

Prophylactic vascular surgery for the asymp- tomatic patient is an area of disagreement at present. For example, should the asymptomatic patient with a carotid bruit have an aortic arch angiogram and possibly carotid surgery? At present I do not believe this warranted. Hope- fully studies presently in progress will soon pro- vide more information on this subject.

ANEURYSMS

Little need be said about abdominal aneurysms except that they are likely to rupture. About 50G of untreated patients with abdominal aneurysms will die within two years of diagnosis. Surgery is now quite standardized and safe, with a mortality rate in our Iowa series of well under 5% for elective resection, but over 40% for emergency surgery. Aneurysmal changes also are apparently arteriosclerotic in nature. Interestingly enough, however, the entire associated arterial tree is usually not only patent but somewhat dilated.

Possibly also of interest is the marked chronic

perivascular inflammatory response so often seen at surgery for chronic arteriosclerotic occlusive disease. These patients often have arteries closely adherent to the surrounding tissues. I will leave these observations for the internist to contem- plate.

One other observation should be emphasized. Almost all surgeons who frequently reconstruct arteries have become convinced that premeno- pausal oophorectomy and cigarette smoking are both major factors promoting precocious athero- genesis. Heavy smokers and female castrates (as well as many diabetics) have vessels which appear 15-20 years older than those of their non-smoking cohorts. Clinically, cigarette smoking is also closely related to both venous and arterial throm- botic conditions.

CONCLUSIONS & SUMMARY

Acute major venous obstruction as in ileo- femoral thrombophlebitis always causes a swollen limb. Acute arterial obstruction never does. There are definite indications and contraindications for both surgery and heparin therapy in such acute situations.

Vena caval ligation should be reserved for patients who develop pulmonary emboli while on an adequate anticoagulation program, and for patients with an uncontrolled septic pelvic phlebitis.

Chronic vascular insufficiency of the lower body, whether at the Leriche level or in the calf, should always be evaluated by translumbar aortography prior to vascular reconstruction. If surgery is applicable the most proximal obstruc- tion should be attacked first. This usually means an aortoiliac endarterectomy or bypass.

Sympathectomy is a useful adjunct to vascular surgery and sometimes offers the only possibility of palliation. A patient with an elevated choles- terol, or a patient who smokes, is not usually a satisfactory candidate for vascular surgery, unless the cholesterol level can be controlled by diet and the smoking is completely stopped. These factors promote atherogenesis and early reocclusion.

Cigarette smoking is known to increase blood coagulability and interfere with fibrinolysin activity. Clinically cigarettes appear to be impli- cated in many thrombotic disease processes. Atherosclerosis requiring surgical evaluation is unquestionably advanced by cigarette smoking, premenopausal castration, and hypercholestero- lemia.

i\'l A R C H 19 6 7

28

NEW CARDIAC CATHETERIZATION LAB

By Frederick R. Hood, M.D. and Arndt von Hippel, M.D.

The cardiac catheterization laboratory at the Providence Hospital has now been in operation for about six months. Equipment includes an image intensifier, a rapid film changer and pressure injector for angiocardiography, Sanborn pressure measuring and recording equipment, and Instrumentation Laboratory equipment for pH and gas analysis.

Diagnostic or preoperative studies have been done on patients with mitral or aortic valvular disease, patent ductus arteriosus, and atrial septal defect. In several cases surgery was found un- necessary or performed elsewhere on the basis of these studies. The patient with the patent ductus arteriosus had his diagnosis established and repair performed in Anchorage.

In the next year we hope to install Cine or T-V video equipment. This will finally make coronary arteriography available in Alaska. Coronary artery visualization for localization of the ischemic area is necessary before surgery is con- sidered. Effective procedures are available for myocardial revascularization, in particular inter- nal mammary implantation, and can now be per- formed in Alaska.

Coronary angiography has been indispensable in evaluating the efficacy of the various surgical approaches to coronary artery disease. It has also been of assistance in the diagnosis of coronary artery disease by providing a source of objective data in addition to the ECG. Fequently Cine coronary arteriography can establish the presence of significant coronary disease. On the other hand normal arteriographic findings offer substantial support for some other etiology of the symptoms.

29

ALASKA MEDICINE

PRESIDENT'S PAGE

Robert H. Shuler, M.D.

The 1967 Convention of the Alaska State Medical Association, as you know, will be in Sitka this year. The dates will be from June 7th to 10th inclusive. The general theme of the convention will be “Common Complaints.” This does not mean we will have common speakers or programs, but that generally, the speakers will be requested to bring things down to the level of practical application.

It is my belief that more participation by our own members should be encouraged in the scien- tific sessions. Please, if you have any kind of scientific paper in mind, or in preparation, let us know. Prograrnming should be complete by April 1, so our speakers can be given an exact schedule.

We plan to have Mr. Roger Connor, an Alaska attorney with much experience in medical-legal cases, and one of the west coast’s outstanding forensic pathologists. Doctor Charles P. Larson. Since the medical liability insurance problem is so important now, I have asked these speakers for contributions to our practical knowledge of “Pre- ventative Legal Medicine.” It won’t be dull!

A few innovations in mind . . .

1. A clam and crab feed on Tuesday evening, June 6th, for those who arrive early (hot dogs also, if you must.)

2. I’m inviting any convention-goer who plays a musical instrument (portable type) to bring it along and we’ll try a combo of our own for a dance after the ASMA Banquet.

Robert H. Shuler, M.D.

President Alaska State Medical Association

3. Wives of the exhibitors will be specifically in- vited to attend all of the Auxiliary events except business sessions.

4. As nearly as possible we’ll try to arrange the scientific sessions in blocks or separate days (Surgery; OB-GYN-Peds; Medical & General) so those who want to enjoy Sitka’s beautiful sur- roundings can plan accordingly. Let’s face it — when we go to conventions away from home, we don’t usually attend all the scientific sessions, so why not make things convenient? We'll have a fishing and sight-seeing committee, naturally.

This year we will make a valiant attempt to keep the business sessions short, and to avoid prolonged discussions of resolutions on the floor. We will try to have two resolution reference com- mittees with time for separate hearings and have resolutions in final form at the general assembly sessions. FOR THIS PURPOSE, ALL RESOLU- TIONS SHOULD BE SUBMITTED BY MAY 1 TO THE OFFICE OF THE EXECUTIVE SECRE- TARY, preferably worded in clear, concise form. We will keep pushing each local society from now on, but members at large should also remember to put their thoughts on paper early. New reso- lutions will not be accepted after the first day of the meeting except by unanimous vote of the full assembly.

You will receive an annotated copy of the ASMA budget a month before the meeting. This also should save time in discussion in the general assembly meeting.

By Council action November 5th, the tradi- tional reports from Federal and State agencies will be eliminated, and if possible, these reports will be presented in ALASKA MEDICINE.

If you do plan to attend the convention, par- ticularly by driving to Haines or coming through Skagway, make reservations on the Alaska Ferry System as soon as possible. If you do drive, unless you intend to go on south from Sitka, I’d suggest you leave your car at Haines or Skagway. There will be little need for your auto in Sitka, and you can buy a lot of cab fare for the shipping expense; besides which I understand the auto transporta- tion is on a first-come, first-serve basis, with no implied guarantee even though the auto fare is paid in advance. Anchorage members and detail men might think about a charter flight direct to Sitka’s new airport.

The new Centennial Center in Sitka will be finished in time for the convention and will be a fine, centrally located place for a good show.

WELCOME TO SITKA IN ’67.

MARCH 1967

30

AUTO TRANSPORTATION POSSIBILITIES TO SITKA FROM NORTHERN ALASKA FOR ANNUAL ASMA CONVENTION

Only direct Ferry to Sitka leaves Haines 10:30 AM June 5th — arrives Sitka

11:55 PM June 5th.

Ferry and Plane Connections to Sitka

June 6th	Depart Haines (ferry)	11:55 PM
	Arrive Juneau ... . Depart Juneau (Alaska Coastal	6:00 AM	June 7th
	Airlines)	9:15 AM
June 7th	Arrive Sitka	10:15 AM
Depart Haines (ferry)	10:30 PM
	Arrive Juneau . Depart Juneau (Alaska Coastal	4:00 AM	June 8th
	Airlines ....	9:15 AM
	Arrive Sitka ...	10:15 AM
	Ferry Return to Haines from Sitka
June 10th	Depart Sitka ...	8:45 AM
June 11th	Arrive Haines .	1:30 AM	June 11th
Depart Sitka	9:15 AM
	Arrive Haines	2:00 AM	June 12th

AIR TRANSPORTATION POSSIBILITIES TO SITKA FROM ANCHORAGE FOR ANNUAL ASMA CONVENTION

Plane Connections to Sitka

-June 6t_h Depart Anchorage (Cordova) 10:00 AM

Depart Anchorage (PNA) 7:00 AM

Arrive Juneau (Cordova) 3-25 pjyj

Arrive Juneau (PNA) 12:05 PM

Depart Juneau (Alaska Coastal Airlines) 2 00 PM

1 Sitka " 3:00 PM

June 7th Same as June 6th

Return to Anchorage — Plane

June 10th Depart Sitka (Alaska Coastal Airlines) 9-30 AM

Arrive Juneau ^ io:30 AM

Depart Juneau (Cordova) 5.00 PM

Depart Juneau (PNA) 1J15 pjyj

Arrive Anchorage (Cordova) 6^20 PM

Arrive Anchorage (PNA) 1:50-3:05 PM

June 11th Same as June 10th

AIR TRANSPORTATION IS SUBJECT TO CHANGE. MORE DEFINITE INFORMATION WILL BE FORTHCOMING.

3]

ALASKA

MEDICINE

ALASKA

Med iciiie

Volume 9, Number 2

June 1967

“■C. MEBIC41 CENTER LIBMrv

JUN 26 1967

Proncisco 22

■ ■' '• ',7 . •' •• •

Look how many ways

Thorazine*

brand of

chlorpromazine

can help

	Tranquilizer	Potentiator	Antiemetic
Agitation	•
Alcoholism	•		•
Anxiety	•
Cancer patients	•	•	•
Severe neurodermatitis	#
Drug addiction withdrawal symptoms	#		•
Emotional disturbances (moderate to severe)	•
Nausea & vomiting	•		•
Neurological disorders	•
Obstetrics	•	•	•
Pain	•	•	•
Pediatrics	•	•	•
Porphyria	•	•
Psychiatric disorders
Hiccups— refractory	•
Senile agitation	•
Surgery	•	•	•
Tetanus	•	•

‘Thorazine’ is useful as a specific adjuvant in the above named conditions.

The following is a brief precautionary statement. Before prescrib- ing, the physician should be familiar with the complete prescrib- ing information In SK&F literature or PDR. Contraindications: Comatose states or the presence of large amounts of C.N.S. depressants. Precautions: Potentiation of C.N.S. depressants may occur (reduce dosage of C.N.S. depressants when used concomitantly). Antiemetic effect may mask other conditions. Possibility of drowsiness should be borne in mind for patients who drive cars, etc. In pregnancy, use only when necessary to the welfare of the patient. Side Effects: Occasionally transitory drowsiness; dry mouth; nasal congestion; constipation; amenor- rhea; mild fever; hypotensive effects, sometimes severe with

I.M. administration; epinephrine effects may be reversed; derma- tological reactions; parkinsonism-like symptoms on high dosage (in rare instances, may persist); weight gain; miosis; lactation and moderate breast engorgement (in females on high dosages); and less frequently cholestatic jaundice. Side effects occurring rarely include: mydriasis: agranulocytosis; skin pigmentation, lenticular and corneal deposits (after prolonged substantial dosages).

For a comprehensive presentation of 'Thorazine' prescribing information and side effects reported with phenothiazine deriv- atives, please refer to SK&F literature or PDR.

Smith Kline & French Laboratories

ALASKA MEDICINE

Official Journal of the Alaska State Medical Association

519 W. 8th Ave., Anchorage, Alaska 99501

Volume 9

June 1967

Number 2

TABLE OF CONTENTS

EDITORIAL STAFF

EDITOR- IN-CEIEF

Arndt von Hippel, M.D.

EDITOR

Theodore Shohl, M.D.

ASSISTANT EDITORS

Gilbert Blankinship, M.D. Walter Johnson, M.D.

CORRESPONDING EDITORS Fairbanks —

Edward Meyer, M.D.

Juneau —

Joseph 0. Rude, M.D. Kodiak —

R. Holmes Johnson, M.D. Seward —

Ernest Gentles, M.D.

Sitka —

Edward Spencer, M.D.

EDITORIAL BOARD

Mahlon Shoff, M.D. , Anchorage Russell Smith, M.D. , Petersburg Ted Shohl, M.D., Anchorage C. F. St. John, M.D., Anchorage Nicholas Deely, M.D., Fairbanks Edward Spencer, M.D., Sitka David Ekvall, M.D., Anchorage Levi Browning, M.D., Juneau

BUSINESS and ADVERTISING

Bob Ogden, Executive Secretary 519 W. 8th Ave.

Anchorage, Alaska 99501

SUBSCRIPTION PRICE: $6.00 Per Year Single Copies $2.00 Each

Send correspondence and manuscripts

to Editor-in-chief, 519 W. 8th Ave.

Anchorage, Alaska 99501

Page

PRESIDENT'S PAGE

Robert H. Shuler, M.D 34

COMMISSIONER'S PAGE

W. John Chapman, M.D 36

LOCAL ANESTHESIA TOXIC REACTIONS

James A. Fraser, M.D 38

PHENYLKETONURIA

Irma W. Duncan, Ph.D. Harvey Zartman, M.D.

Donald R. Rogers, M.D 42

FRACTURE CLINIC

J. Paul Dittrich, M.D 48

ALASKA MEDICINE THROUGH THE RETROSPECTISCOPE

Elizabeth A. Tower, M.D 50

NEW STATE LEGISLATION OF MEDICAL INTEREST

Rodman Wilson, M.D 52

TRAINING PROGRAMS FOR PHYSICIANS AND DENTISTS AT ALASKA NATIVE MEDICAL CENTER, ANCHORAGE

M. Walter Johnson, M.D 55

LEGISLATIVE EVENTS

Michael F. Beime, M.D 56

THE LEGISLATURE WILL GET YOU IF YOU DON'T WATCH OUT!

Milo H. Fritz, M.D 62

CAPITOL CITY'S HOSPITAL- -OLD TO NEW

Robert G. Ogden 66

MUKTUK MORSELS

Arndt von Hippel, M.D 68

CASE REGISTRY FOR HANDICAPPED CHILDREN D. V. Reddy, M.D. , M.P.H. and Jon M. Aase, M.D 73

CLASSIFIED AD SECTION 75

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AMA ARCHIVE LIBRARY

76

PRESIDENT’S PAGE

1 9 6 7 may mark a turning point for ours and perhaps for many other State Medical Society memberships as well. For the first time, a law exists Mdiich takes a positive at- titude toward proof of malpractice, and also instructs courts and juries to make their evaluations on that basis. Alaska is the only State at present with such a law on the books; we hope that others will follow suit.

This was a wonderful accomplishment, but how was it done? It took special efforts by many of our members: a willingness to spend money even if we had to dig into our savings (even Dr. Bob Wilkins was pried loose from the “building fund” .) ; cooperation with knowl- edgeable attorneys; time for a trip to Juneau by Dr. St. John, Dr. Rod Wilson and myself. It took the cooperation of our three Doctor- Legislators; plus the political know-how of Attorneys Delaney and Doogan. It took com- promise with members of the legislature on other matters. It took the efforts of a publi- city agent whose grasp of the situation was unquestionably brilliant. Above all, it took the willing cooperation of the Alaska Dental Society, who had as much at stake as we, and were smart enough to see it in advance even though they weren’t in a back-to-the wall sit- uation. They told me that this was the first time they had been invited to participate in a conjoint effort. When I invited them to join our “planning breakfast” in Anchorage, I knew that the attitude of many of our mem- bers was: “Let ‘em fight their own battles”; but I also knew that the Dental Society had grasped the need for positive political action better than we, and shown it in their lobbying during the past three or four years. Without their help, we’d probably be still waiting for action on S. B. 142!

Why bring this up?? Because it points the

way for future action which will be even more important to our lives as physicians. We can- not accomplish anything by censure versus understanding. Far too many of us, (with a psychological reaction that above all others should be able to evaluate objectively) could think only of striking out at the legal profession. From all sides came the ringing call: “Let’s fix those &*%##^ lawyers so

they can’t collect so much money from these cases, then maybe they won’t be so anxious to crucify us”. Memory is short, indeed! In 1965 and 1966, in our conventions, we passed resolutions which set our fees at the rates we thought best. We refused, by golly, to let any agency or group tell us what our charges should be!

We face more problems in the near fu- ture. As yet, Alaska legislation hasn’t im- plemented any of the necessary laws for Title XIX of Medicare which must be on the books by 1970, or the State can be refused ^ Federal grants dealing with Health, Education and Welfare. Instead of destroying our own public image and chances for the respect of our own patients, even our own families, we’d better be willing to work, to cooperate, even though we feel the whole concept is abomin- able. WE MUST WORK WITH THE LEGIS- LATORS IN THE NEXT TWO YEARS TO PRE- PARE AN ACCEPTABLE PLAN, OR BE WIL- LING TO HAVE A FAR LESS ACCEPTABLE ONE FORCED UPON US. Remember, it was compromise, understanding and cooperation which enabled the ASMA to persuade, not force, our legislators to write the 1967 Mal- practice Act into law. Let’s keep on being Alaska pioneers, and accept our new role as physicians to society as well as to the indivi- dual.

It’s unusual, perhaps, to thank someone

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ALASKA MEDICINE

for handing one a tough job, but I do want to thank you for the worry, expense and extra work of this year as your President. It’s a magnificent way to learn more and more about the other guy, the other professions, the reasons for our present status. I hope I’ll never be complacent again.

Dr. Bob Wilkins, your President for 1967- 68, has already spent more time and effort for the ASM A than anyone I can name, as Secretary-Treasurer for many years. Please

thank him by giving him the same cooperation you’ve given me, and rejoice, rejoice with us because there’ll be the able and enthusiastic assistance of our new Executive Secretary, Mr. Bob Ogden.

Sincerely,

Bob Shuler

(you might say that the ASMA is riding on a Bob-sled these days!)

Robert H. Shuler 3 M.D.

ALASKA MEDICINE

JUNE 1967

PAGE 35

COMMISSIONER’S PAGE

By W. John Chapman, M.D.

Commissioner

De-partment of Health and Welfare State of Alaska

President Johnson has enunciated a changed concept of the Federal government’s role in relationship to the States. Oddly, there seems to be little general awareness of the significance of this change of direction. In essence, the States will be expected to de- termine their own needs, develop programs, and establish priorities for programs without the interference and direction of the Federal government, which will function primarily as a resource for money, manpower, and con- sultation.

The new approach is characterized by block grants of money which the States may distribute to their programs, based on their own priority system and expend as they de- termine the need. This is in contrast to the former focus on category grants wherein Fed- eral guidelines were supplied to each pro- gram and programs were tailored to meet the Federal requirements.

Needless to say, there are some controls placed on this new process. The Act pro- vides a specific inducement to the States to plan comprehensively according to Federal guidelines in order to meet specific objec- tives. The Surgeon General is empowered to interpret the intent of Congress, and does so through the use of “guidelines.” There is, in my opinion, the implicit - thou^ unspoken - clear intention of the Federal government to intercede and impose its own programs and enforcement where it is legally able, if the States fail to rise to the challenge of self-

PAGE 36

determination of their health programs in- sofar as they are open to Federal purview.

Johnson views this total process as “crea- tive federalism.” It was Secretary Gardner of the Department of Health, Education and Welfare, who first coined the term a number of years ago and applied it to a concept which has, in essentials, become what we see today.

Admittedly, this is an incomplete picture of this complex new social development, but one which should serve to focus attention on this change in Federal emphasis.

One of the most significant Acts of social legislation in the 89th Congress - and, in fact, in recent times - was the Act entitled “Com- prehensive Health Planning Act of 1966,” also known as Public Law 89-749. This Act is in keeping with the new Federal concept of “creative federalism,” the effect of which is to prompt the State to take the initiative in the development of its own health programs. The Act stimulates comprehensive health planning which will tend to effect the best possible development and integration of all health resources - State, local. Federal, and private non-profit and profit-making agencies - for the promotion of the best possible level of health for Alaskans.

Our Alaskan Department of Health and Welfare is unique among the States in that it encompasses a very broad spectrum of social services, including the Youth and Adult Authority, Public Welfare, Public Health, and Mental Health Divisions. PL 89-749 presents

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for us a particularly useful catalyst for plan- ning since we cannot limit ourselves to com- prehensive health planning, but must instead plan comprehensively beyond the limits of the usual concept of health in order to promote the total social and physical well-being of Alaskans.

Governor Hickel has designated the State Department of Health and Welfare as the of- ficial planning agency for the development of the potential of the Comprehensive Health Planning Act. The Act makes funding avail- able for the creation of an Office of Com- prehensive Planning in the State Department of Health and Welfare, as well as a Citizen Advisory Council to advise the Department in comprehensive planning. Duringthe last ses- sion, the State Legislature passed Alaska Statute No. 270 which allows the formation of the Advisory Council required by this Act. It is interesting that “consumers” must con- stitute the majority membership of this Council.

Development of area- wide comprehensive planning agencies which will integrate their comprehensive plans with those of a State- wide nature is also envisioned and provided for by this Act. This will allow boroughs, for example, to develop comprehensive health plans with the aid of funding under this Act. Federal money will be available to local agencies through the State Department of Health and Welfare to promote their pro- grams in keeping with a comprehensive plan for the State as a whole.

Funding for programs undertaken as part of the overall State plan will be made avail- able on a block grant basis, as provided for under one section of the Act, thus giving the State freedom to channel the money according

to its own needs. This is distinct from the categorical grants of the past.

Another interesting provision of this Act is that it permits the exchange of personnel. For example, Federal health employees may be assigned for periods of up to 2 years to State agencies involved with health activities.

One important result of this Act will be the promotion of an effective mutual in- volvement in health and welfare planning with the Alaska Native Health Service and the Bureau of Indian Affairs. Plans and discus- sions leading toward the development of this cooperative involvement are now under way.

We view this legislation as a very welcome opportunity to develop self-determination of our health and welfare needs. We will look to the medical profession for ideas, sugges- tions, and involvement in all comprehensive planning. The medical profession cannot be excluded from any significant planning for the State of Alaska. We must develop a coopera- tive relationship in the best tradition of medi- cal practice.

“Constructive statism” expresses our basis for development in the Department of Health and Welfare. We shall carry the ball in Alaska and look to the federal government for funding, manpower, and consultation. In short, we shall view the Federal government as our resource partner. This is the opportu- nity which we see in “creative federalism.”

This represents the most exciting and challenging development in the field of health and welfare at the present. However, it is by no means the only development under way. I look forward to being able to discuss our plans and programs with you in future issues of Alaska Medicine. I hope that you will give me the benefit of your views and suggestions in return.

ALASKA MEDICINE

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LOCAL ANESTHESIA TOXIC REACTIONS

By Dr. James A. Fraser

In a momentous demonstration before the Opthalmoiogical Congress at Heidelberg in 1884, Karl Koler demonstrated the topical anesthetic properties of cocaine. Within a short period of 12 months the newly discov- ered drug was tested in every major clinic in the world, and the utility of cocaine as a topical agent was tried in every form of in- tervention in which the insensibility of ex- posed surfaces could be of benefit to man. Halstead and associates began work within one week of the arrival of Koler’s paper, and that year performed the first premeditated nerve block by injection. In 1885 Corning performed the first spinal and epidural pro- cedures. This is in great contrast to the very slow development of general anesthesia.

Numerous toxic reactions were soon seen, stimulating search for better agents. In 1904 E inhorn introduced Novocaine, the first syn-

thetic agent. A great number of other local anesthetic drugs have been produced since then.

The current classic reference test on local and regional anesthesia drugs and pro- cedures is REGIONAL BLOCK by Moore; 4th Ed., 1965, Charles C. Thomas Publisher. It should be available to everyone performing block anesthesia procedures.

CLASSIFICATION

At present there are about 10 generally available local anesthetic agents. Moore classifies them in groups according to chem- ical structure. If a patient is known to have a true allergic sensitivity to one specific drug, a local anesthetic drug of another chem- ical group may usually be used without pro- ducing a reaction.

Average Maximal Dose*

Chemical Name Brand Name for Healthy Adults Common Use

	/ P roca i ne	Novoca i ne	1000 mgm.	Infiltration & Spinal
	1 Tet raca i ne	Pontoca i ne	125 mgm.	Infiltration, Spinal &	Top i ca 1
Benzoic	1 Ch 1 oroproca i ne	Nesaca i ne	1000 mgm.	1 nf i 1 1 rat ion only
Acid Esters	N Coca i ne		100 mgm.	Topical only
	j P i peroca i ne	Metyca i ne	1000 mgm.	1 nf i 1 tration only
	( Diethoxi n	1 ntraca i ne	1000 mgm.	1 nf i 1 tration only
	/ L i doca i ne	Xy 1 oca i ne	500 mgm.	Infiltration, Spinal S	Top i ca 1
Chemi cal ly	I Mep i vaca i ne	Carboca i ne	500 mgm.	Infiltration, Spinal £	Top i ca 1
unre 1 ated	\ 0 i buca i ne	Nuperca i ne	AO mgm.	Spinal only
compounds	f Hexy 1 ca i ne	Cycl a i ne	500 mgm	Infiltration £ Topical	only

* Within these dose levels and common use categories , approximately equal safety may be assumed.

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ALASKA MEDICINE

A new agent, Propitocaine (CitanestR) has recently been introduced. It is chemically related to Xylocaine. Early reports from the literature indicate that it has a wide safety margin because of a high maximal dose limit and it may enjoy wide clinical use in the future.

Several hundred other caine t3T)e drugs have been discovered, but most are not used clinically. Many are neurotoxic, others have a very hi^ incidence of toxic reaction.

TOXIC REACTIONS

Systemic toxic reactions maybe due either to true allergic sensitivity or to high blood levels of the drug, and the latter probably accounts for over 99% of cases. These are commonly known as Cocaine Reactions. Co- caine has probably been the most common cause of local anesthetic reactions as the allowable maximal dose is quite small (See table). Moore lists a number of factors of practical importance which lead to high blood levels.

1. Intravascular Injection — This is the most obvious cause, and can usually be avoided by careful aspiration for blood at each injection area. These areas include the head and neck, epi- dural spaces, trachea and lung. The mucous membranes of the airway ab- sorb drugs very rapidly. Indeed, ab- sorbtion from the lung itself is almost as rapid as intravenous injection. Vasoconstrictor drugs decrease locsd blood flow and slow absorbtion. Therefore, when large doses are used, particularly in vascular areas, the use of a vasoconstrictor is frequently helpful.

2. Individual susceptibility — As with most drugs, some patients , particu- larly the debilitated and the elderly, detoxify drugs more slowly. The liver detoxifies most local anesthetic drugs.

Cocaine, however, is excreted un- changed by the kidney. If a drug is detoxified more slowly than normal, it will reach higher blood levels, and these blood levels will last longer. The sum of repeat doses should not exceed the maximal dose at onetime. Maximal dose blocks maybe repeated at a later time, when the effects of the first begin to wear off.

3. Excessive doses and concentrations — More concentrated solutions are ab- sorbed more rapidly than an equal miligram dose in a more dilute solu- tion.

4. Total weight of drug injected — T h e maximum doses of drugs in use must always be remembered and never ex- ceeded.

5. Use of spreading agents --Hyaluroni- dase can cause a 40% increase in the absorptive area, increasing the rate of absorption similarly.

A number of tests to predict possible ab- normal responses to local anesthetic drugs have been proposed in the past. They are not generally used today as they are not reliable. A good history is all important.

SIGNS AND SYMPTOMS

The signs and symptoms of systemic toxic reactions to local anesthetic drugs are sum- marized in the table below.

I. Toxic Reactions in Normal Individuals

A. CNS effects 1. Stimulatory

a. Cortex — excitement, nervous- ness, incoherent speech, con- vulsions

b. Medulla

(1) Respiratory — tach5q)nea, irregularity

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(2) Vascular — Increased blood pressure and heart rate

(3) Other — vomiting

2. Depression

a. Cortex — unconsciousness

b. Medulla

(1) Respiratory — decreased

(2) Vascular — decreased blood pressure and heart rate

B. Peripheral Effects

1. Cardiovasular

a. Direct on heart — bradycardia

b. Vascular bed — vasodilatation

II. Abnormal Responses

A. Allergic reactions

1. Skin — urticaria, etc.

2. Respiratory \ Anaphylactic

3. Cardiovascular/ shock

III. Reactions not due to the anesthetic agent

A. Psychomotor — fainting, etc.

B. Vasopressor effect.

All t3^es of reactions maybe encountered simultaneously to a varying degree in one and the same case, and the preponderant symp- toms will determine the therapy. However, most reactions do follow general patterns. The reaction may be immediate or delayed in onset, depending on how rapidly the high blood level is reached. Early signs of CNS stimulation include restlessness, nervous- ness, agitation, apprehension, incoherent speech, nausea and vomiting, dizziness, blur- red vision, twitching. Severe reactions pro- gress, perhaps rapidly, to convulsions. In early stages the respiratory rate and excur- sion may increase, later become irregular, and in severe reactions apnea ensues. Like the respiratory signs, cardiovascular signs show an early increase in readings which may progress to a severe depression.

TREATMENT

The initial treatment of any toxic reaction

to a local anesthetic drug, whether the mani- festations be central nervous system or vas- cular, stimulation or depression, is oxygen. This is best administered by bag and mask or endotracheally. The metabolic rate of the brain is greatly increased under the influ- ence of pharmacologic stimulation. Unless the oxygen supply is increased significant hypoxia will result, and increase the severity of the symptoms. After the oxygen is started, intravenous fluid administration should be started to aid possible further therapy.

If convulsions ensue, oxygen remains the first drug to use. Oxygen is also helpful in seisures from other causes. As mentioned above, the stimulated brain has an increased metabolic rate, and, in the presence of con- vulsions, respiratory exchange will be sev- erely decreased. If this does not stop the convulsions, the choice of further drugs will depend on the knowledge of the person in charge and the equipment available. The treatment of choice is the muscle relaxant succinylcholine (Anectine, Quellicin) 40 mgm. intravenously. This will completely paralyze all skeletal muscle for three to five minutes, so that optimal manual ventilation is neces- sary. If succinylcholine is not available, then Pentothal (Thiopental) in 50 to 100 mgm. doses, given in intervals of one to three min- utes, may be used to stop the convulsions and allow oxygenation. Large doses of bar- biturates significantly deepen the depression of the brain centers that follow conwilsions.

Convulsions, caused by local anesthetic reactions, which do not respond to the above treatment are rare, but require very vigorous treatment. General anesthesia should be in- duced. This can be done by giving about 250 mgm. Pentothal and 4 to 7 cc d-tubocurarine intravenously, intubating the patient and ven- tilating with oxygen. If muscle relaxants are not available, inhalation anesthesia with Fluo- thane or Ether should be used. The Anes-

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thesia may be lightened at 30 minute intervals until the seizures have ceased.

Adequate oxygenation will often stabilize the cardiovascular system. If h5q)otension ensues, an intravenous vasoconstrictor such as Neosynephrine (Phenylephrine) should be used. Cardiac standstill is more common than ventricular fibrillation, assuming oxy- genation has been adequate and should be treated with cardiac massage and the usual cardiac drugs.

TRUE ALLERGIC REACTIONS True allergic reactions to local anesthetic

drugs are very uncommon, probably causing less than one percent of all local drug reac- tions. Contact dermatitis frequently affects people who administer these drugs. This is an important reason why gloves should be routinely worn when handling these solutions. Generalized systemic allergic reactions may also occur, and cause angioneurotic edema, urticaria, arthralgia, asthma, G. 1. upsets, and true anaphylactic shock. Treatment of these may require Benadryl, Adrenalin, Hy- drocortisone, and Aminophylline in the usual doses.

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PHENYLKETONURIA

By Irma W. Duncan, Ph. D.

Arctic Health Research Laboratory Anchorage Alaska

Chairman^ Governor's Advisory Committee for Mental Retardation

Note: The following information about phenylketonuria (PKU) has been prepared at the suggestion of the Gov- ernor’s Advisory Committee for Mental Retardation Pro- gram Planning in the belief that readers of ALASKA MEDICINE are interested in having more detailed infor- mation on this condition.

During recent decades knowledge about inherited diseases which lead to mental defi- ciency or other serious illness has advanced markedly. By August 1 966 , 34 states including Alaska had enacted legislation concerned with screening programs for phenylketonuria (PKU)’ , a rare inherited disease which, if not treated in infancy, usually results in mental retardation.^ Although the Alaska law was passed in April 1965, * it has not been fully implemented, largely it is believed, because of a lack of understanding of the underlying factors.

Phenylketonuria was first recognized as an inherited disorder of phenylalanine metab- olism in 1934 by Foiling, a Norwegian phy- sician. Treatment did not become available until two decades later? The reported inci- dence of PKU is 1 in 8-10,000;^ however, the results of some recent screening programs indicate that the incidence may even be as high as 1 in 5,000.^ Incidence is the same among Europeans, Americans and Japanese but lower among Jews and Negroes.^ At present, approximately 1% of those institu- tionalized for mental retardation have this disease.*

Since phenylalanine occurs in all natural protein foods, the ingestion of proteins will cause phenylalanine as well as the other amino

PAGE 42

acids to appear in the blood. In the normal person, most of the phenylalanine is converted to tyrosine by an enzyme normally in the liver. An individual with phenylketonuria (a phenylketonuric) lacks this enz5rme and therefore lacks the ability to convert the amino acid phenylalanine into the amino acid tyrosine. In a phenylketonuric, phenylalanine and related substances rise to higher levels in the blood than in normal persons; these substances are excreted in the urine. One of these abnormal substances is phenylpyruvic acid which belongs to a class of compounds called ketones; hence the name, phenylke- tonuria.

Since the level of phenylalanine does not increase until after absorption of a protein meal , testing the infant at birth will not reveal the enzyme deficiency. However, in the infant afflicted with PKU, phenylalanine will rise above normal levels in his blood within 24 to 48 hours after the starting of milk feeding.^ The resultant chemical environment of the developing brain is so altered that normal de- velopment does not occur; the reason for this is not known at present.

Timing of Screening Tests — The phenylalan- ine in the blood may be higher for some days, even weeks, before phenylpyruvic acid or phenylalanine will be detected in the urine. Therefore screening tests on infants under 4-6 weeks old should be done on blood samples . Since the early weeks of life are a very im-

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ALASKA MEDICINE

portant period for brain maturation, early di-

3 5 7

agnosis and treatment are essential. ' ' Caution must be used in interpreting the screening tests. A diagnosis of PKU is not made and treatment is not started until re- sults of the blood tests have been confirmed by another method.^ About 1 in 2,000 infants three to five days old will have a phenylalan- ine blood level considered intermediate be- tween normal and grossly abnormal levels.^ This rise may be transient or it maybe con- firmed by a later test. Such transient rises are often observed in premature infants. Some of the PKU infants may have ingested such small amounts of milk before their dis- charge from the hospital that the blood pheny- lalanine at the time of testing will be normal. A follow-up test at approximately one month should be performed to confirm the results of the earlier test.

Methods of Screening — Phenylalanine maybe determined by chromatography, by a chemical method using a fluorometer,’ or by the bac- terial inhibition test (Guthrie)’®. Chromoato- graphy is generally not used where large numbers of samples are involved. The bac- terial inhibition test is simple, inexpensive and reliable.” Special paper is saturated with several drops of blood from a finger or heel prick. A disc of standard size (about 1/3 inch) is punched from the dried blood- soaked paper. The use of such a disc meas- ures the same amount of blood in each test and allows the results to be reported as the weight of phenylalanine per a standard volume of blood. The blood discs and additional discs impregnated with various known amounts of phenylalanine are placed on a solid culture medium, which contains certain bacteria and a chemical which inhibits the growth of the bacteria, and incubated for 18 hours. Pheny- lalanine counteracts the chemical inhibitor and allows the bacteria to grow. The amount of phenylalanine present may be estimated by the extend of growth of the bacteria which

appears as an opaque white area or halo around the paper disc. The discs containing the known amounts of phenylalanine serve as standards for comparison.

The chemical analysis for phenylalanine by a fluorometric method is used to confirm any sample considered abnormal in the screening. This method is also used for screening and may be more widely used as automated methods become practical.

Who Does the Screening — In most of the heavily populated states the screening is done by personnel of the State Health Department Laboratory.’ In 4 or 5 states private hos- pitals, designated by the state as regional centers, perform the tests.’ Generally only a large laboratory will perform a large enough number of tests with above normal levels of phenylalanine to acquire skill in reading the results. Mailing of the blood-soaked paper discs has proved satisfactory.

The urine test for phenylpyruvic acid is simple; it may be performed by a nurse in the doctor’s office and may also be used by the parents at home for monitoring of diag- nosed cases. A green color is produced when ferric (iron) chloride is added to the urine or when a paper impregnated with a ferric salt (Phenistix) is dipped in the urine. This test is useful for the screening of adults and chil- dren over 4 weeks old.

Treatment- -The treatment for PKU is to eliminate from the diet almost all of the phenylalanine. Since all natural protein foods are good sources of phenylalanine and protein is essential in the diet, the main part of the PKU diet is synthetic. This synthetic diet is usually prepared from a hydrolyzed casein treated to remove the phenylalanine and then fortified so as to provide an adequate protein diet except for the phenylalanine.

Since phenylalanine is an essential amino acid a certain low level must be maintained in the blood or symptoms of malnutrition will appear. ' The child must have very small

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PAGE 43

amounts of milk and other proteins for ade- quate development. He may also have fruit, some vegetables, some cereals, sugar and starch. Water is added to the synthetic part of the diet and this is used as one would use milk. A baby usually accepts this formula. The diet is not difficult to administer during the bottle feeding stage but it is difficult to maintain when the toddler is able to forage for himself. If treatment is started early, the child may be expected to develop normally. Dietary treatment instituted as late as age 2 may help, but the child will probably not be normal’.’ As the child gets older, the severe dietary restrictions may be relaxed.^ Cur- rent experience indicates that a child may tol- erate a normal diet by six to eight years of age. His chemistry remains abnormal but his brain can tolerate this after a certain stage of development has been reached. The treat- ment of PKU requires an expert, well-inte- grated team, composedof pediatrician, nutri- tionist, public health nurse, social worker and laboratory technician!^ Hospitalization is usually unnecessary.'^ Treatment should be carried out in the home under supervision, where the parents may provide the affection, stimulation, discipline and security neces- sary for normal behavioral development. Diagnostic Signs — There are no truly diag- nostic physical signs of the disease. The new- born appears normal; his skin and hair are usually lighter than those of his parents. Eczema, seizures and extreme irritability often occur. The odor of the urine may be musty. If untreated by the time he is three to four months old the child’s development may be noticeably slowed. By 2-3 years his intelligence, and sometimes his physical growth, is definitely below normal. Some children with PKU never learn to walk; many never learn to talk. While 10% of individuals with PKU who do not receive treatment may be only mildly retarded, and another 0.5% may be judged to have normal intelligence; the

great majority will need to be institution- alized.

The small percentage of those untreated PKU children and adults diagnosed as PKU individuals but who appear to possess normal intelligence is cited by some as evidence that the claims for the dietary treatment are not valid. However, reports comparing the in- telligence of phenylketonurics treated from early infancy with that of late-treated siblings indicate that the majority of these treated soon after birth appear to be normal.” When a group of treated phenylketonurics is com- pared to a comparable group of untreated cases, the marked contrast in intelligence is an unquestionable validation for diet therapy.’"* Secondary pathological changes due to the diet have been shown to be due to an incomplete follow-up in the treatment program.’^

The recognition of phenylketonurics with normal intelligence also indicates a need for testing adults, especially pregnant women. A woman afflicted with PKU may be delivered of a child not afflicated with PKU but who has suffered brain damage m utero because of the abnormal levels of phenylalanine and related ■substances in the mother’s blood.’

A female baby who grows to normal adulthood through dietary treatment, may produce a baby who is not a phenylketonuric but who may be brain damaged unless the mother’s blood phenylalanine is controlled successfully dur- ing pregnancy. The first successfully treated girls are now twelve years old.

Operation and Costs of Program — The cost of any program is of course important to the public. To date, experience in other states has averaged about fifty cents per newborn tested, including a follow-up test at 4-6weeks.^ As- suming an incidence of PKU in Alaska similar to that in other states and countries, a com- plete testing program may be in force for two years before one case is discovered. Even assuming that screening each newborn would cost the state $1.00, the cost for these two

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years of testing would be $ 16,000 (8,000 births per year). Compare this to $100,000 which is a modest estimate for the lifetime care of one individual institutionalizedfor mental re- tardation.

Although extensive testing and an effective program can be conducted without mandatory legislation, experience in other states has in- dicated that legal requirement of such tests is more likely to insure every child’s “bill of rights” than a voluntary testing program. However, merely ordering screening tests by law does not guarantee an effective program. As emphasized earlier in this article, detec- tion is but the first step in a long-term treat- ment program.

Since most infants are born in hospitals where appropriate screening tests can easily be performed, the program should be initiated in the hospital. Moreover case finding in the neonatal period facilitates the early inaugura- tion of therapy. Because of the high cost of hospitalization and adequate care for other young children in the home, some mothers and babies leave the hospital sooner than three days afterbirth. Records of each child’s feed-

ings may be consulted and the pediatrician and public health nurse alerted if the baby was discharged and the blood sample taken before enough feedings had been given to test the possibility of PKU.

Much remains to be discovered about phenylketonuria. The fact that our knowledge is incomplete does not mean that we cannot utilize to advantage the information we al- ready have.” Utilization of screening tests, confirmation of any positive tests, a second test at about one month of age and careful monitoring of all for whom the special diet is administered promises greater hope than ever before for the mentally retarded. Tech- niques are already available by which it is possible to screen a bloodspot for a variety of inborn errors. Other diagnostic

tests require serum and/or urine samples. These new techniques are not yet widely used for screening, but it is evident that develop- ment of a testing program in one area serves to stimulate research in other areas and spurs the development of community programs with broad preventive implications.

1. Children’s Bureau, Dept, of Health, Education and Welfare. Personal Communication. 1966.

2. Umbarger, B., H. Berry andB. Sutherland. Advances in the Management of Patients with PKU. J. Am. Med. Assoc.. 193:784-790. Sept. 6, 1965.

3. MacReady, R..A. and M.G. Hussey. Newborn Phenyl- ketonuria Detection Program in Massachusetts. Am. J. Public Health, 54:2075-2081. December 1964.

4. Cooper. M. S. Hospital PKU Screening Laboratory Serves 65 Hospitals. Hospitals, 40:69-74. January 16. 1966.

5. Wagner. M. G. and B. Littmen. Phenylketonuria in the American Indian. Pediatrics. 39(1):101-110. January 1967.

6. Children’s Bureau. Dept, of Health. Education and Welfare. Phenylketonuria. Publication No. 388. 1961.

7. Cunningham, G. C. Phenylketonuria. Calif. Med. 105:1-7. July 1966.

8. Barlet, H. H. Aspects of Amino Acid Metabolism in Phenylketonuria and other Amino Acidopathies. Progr. Brain Res. 16:184-215. 1965.

9. -McCaman, M. W. and E. Robins. Fluorometric Method for the Determination of Phenylalanine in Serum. J. Lab. Clin. Med. 59:885-890. May 1962.

10. Guthrie. R. and A. Susi. A Simple Phenylalanine Method for Detecting Phenylketonuria in Large Pop- ulations of Newborn Infants. Pediatrics. 32:338-343. September 1963.

11. Haab. W. et ai. Validation of a Modification of the Guthrie Test for Phenylketonuria. Am. J. Mental Deficiency. 69:790-793. May 1965.

12. Knox, W. E. An evaluation of the Treatment of Phenylketonuria with Diets Low in Phenylalanine. Pediatrics. 26:1-11. July 1960.

13. Committee on Fetus and Newborn. Screening of Newborn Infants for Metabolic Disease. Pediatrics. 35:499-500. March 1965.

14. Kang. E. S. et al. Clinical Observations in Phenyl- ketonuria. Pediatrics, 35:932-943. June 1965.

15. Rouse, B. M. Phenylalanine Deficiency Syndrome. J. Pediat.. 69(2):246-249. August 1966.

16. Fisch, R. O. et al. Pre-Natal and Post-Natal De- velopmental Consequences of Maternal Phenylketon- uria. Pediatrics. 37(6):979-986. June 1966.

17. Mabry, C. C. et al. Mental Retardation in Children of Phenylketonuric Mothers. New Engl. J. Med., 275(24):1331-1336. December 15, 1966.

18. Editorial. Maternal Phenylketonuria. New Engl. J. Med.. 275(24):1379-1380. December 15. 1966.

19. Berry, H. K. and S. Wright. Conference on Treat- ment of Phenylketonuria. J. Pediat.. 70(1):142-147. January 1967.

20. Perry, T. L.. S. R. Hansen, and L. MacDougall. Urinary Screening Tests in the Prevention of Mental Deficiency. Can. Med. Assoc. J. . 95(3):389-395. July 16. 1966.

21. Efron, M. L. etal. Simple Chromatographic Screen- ing Test for Disorders of Amino Acid Metabolism. New Engl. J. Med., 270(26):1378-1383. June 25. 1964.

22. Renuart, A. W. Screening for Inborn Errors. New Engl. J. Med.. 274:384-387. 1966.

23. Children’s Bureau. Dept, of Health. Education and Welfare. Rare Inborn Errors of Metabolism in Chil- dren with Mental Retardation. Publication No. 429 1965.

♦{Laws of Alaska, Chapter 90. Section 1. Article 6)

ALASKA MEDICINE

JUNE 1967

PAGE 45

PKU DISCUSSION

In reading the article on phenylketonuria by Doctor Irma Duncan, at your request, I am impressed with the wealthof research and the bibliography that she uses to back up her rea- soning. I am taking the liberty of enclosing a monthly bulletin put out by the American Academy of Pediatrics (April 1967) and have quoted a comment which does not have a bib- liography behind it, but has a wealth of expe- rience on the part of numerous pediatricians, to the effect that the mandatory PKU legisla- tion is poor, primarily because it is based upon unwarranted medical assumptions.

H. R. 9J3 -- A b-M to mznd thz Pubtic. HzaZth

AcX tn oKdzn to pnomotz thz dztzctxon OjJ ph&nyZkztonuAta. and othzA tnboAji ejiKOHM o{^ meXabotlbm IzacUng to mzntaJL K^toA-datton on. pkyilcjoUL dzj^zctd.

In our view, ^ this is a poor piece of legislation, one with nable aims, but based upon unwarranted medical as- sumptions.^ ye dw not believe that, at this time, we have sufficient knowledge concerning either the correct and early diagnosis of inborn errors of metabolism, nor the%r effective management, to warrant this kind of VMic health programming . The funds needed to support th%s legvslation would be much better utilized to fur- ther research in this field.

This same feeling is again expressed by Doctor Gellis in editorial comments in the Yearbook of Pediatrics for 1967. Unfortuna- tely , the articles that Doctor Duncan cites come to different conclusions and it gets to be a matter of opinion rather than a scientific fact. Certainly we want to do all we can to

prevent any severe mental retardation that is as apparently preventable as that due to phenylketonuria. To this effect, most pedia- tricians have for many years tested the urine with ferric chloride, either by putting drops of this material on the diaper or by using the Phenistix in a urine sample or in the diaper at the six- weeks check. Though I have yet to find a case of phenylketonuria, I will continue testing every baby as long as I am in the active practice of pediatrics. When the state legis- latures pass laws ordering testing to be done in the newborn nursery, the real problem above and beyond that of expense is the re- moving of the onus of follow-up and detection from the shoulders of the doctor who will con- tinue the care of the child. The net result is more likely to be that babies will not be checked at six weeks or at four weeks, de- pending on the routines of various physicians, and that without a central authority checking on every newborn test and following up on every positive or suggestive newborn test, the few cases that might be detected may remain undetected until too late. There are so many detectable problems that could be uncovered in the newborn period that occur with greater frequency and with equal devastation to the in- dividual child and with even more possibili- ties for correction, that it would seem that too much time, effort and money is being was- ted on this relatively uncommon disease with variable success as far as treatment is con- cerned at the present time.

HARVEY ZARTMAN, M.D.

Anchorage Pediatric Group

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JUNE 1967

ALASKA MEDICINE

PKU DISCUSSION (continued)

Thank you for allowing me to review the Article on PKU by Dr. Duncan.

While I have no special quarrel with the description of the biochemistry of the disease and its clinical features, there are several points which might be made regarding the pro- posed mass screening program. My thoughts are obviously those of a newcomer to Alaska, possibly with an inadequate knowledge of state-wide problems.

It would seem that the expenditure of large amounts of money to discover an occasional example of a very rare disease is dispropor- tionate to its importance. Especially so since many mundane diseases, such as tuberculosis and measles, still are important in Alaska (and elsewhere, for that matter). Further, most doctors probably are adequately screen- ing their patients within the limits that re- moteness, lack of communications, and diffi- culty in follow-up impose. Legislation cannot solve these problems. Probably most chil- dren who do not receive a routine screening test for PKU do not because of their location, and so forth, rather than ignorance on the part of the local doctor. Of even more importance, however, is the experience of some workers in the field suggesting that mass screening programs are not working as well as had been expected. In a recent article in Medical World News, abstracted from the New York State

Psychiatric Journal, Dr. S. P. Bessman, of the University of Maryland, points out that many adults have been discovered with high levels of phenylalanine and normal intelli- gence, and many children of these mothers have normal phenylalanine levels but later develope the PKU syndrome anyway. Further, the incidence of high levels of phenylalanine in children is much higher than the incidence of the disease, showing again that the disease is not directly related to the chemical finding. He suggests that at least some of the apparent improvement in children with early mental retardation, and the lack of development of retardation in others may be more the result of increased attention and training than the amino acid deficient diet to which they are subjected.

It would seem that perhaps it might be prudent for Alaska to profitby the experience of others and at least await more encouraging results from elsewhere before embarking on this admittedly expensive program.

Donald R. Rogers, M. D. Director of Laboratories Anchorage Community Hospital

ALASKA MEDICINE

JUNE 1967

PAGE 47

FRACTURE CLINIC

Fracture of the Lateral Malleolus

By J. Paul Dittrich, M.D.

Fracture of the lateral malleolus of the ankle is a relatively common injury. It is produced by a lateral rotation stress of the foot, twisting the talus in a lateral arc with the anterior margin of the dome of the talus striking the inner aspect of the lateral mal- leolus, causing it to fracture just above the ankle joint. The course of the fracture line is remarkably constant in these injuries, be- ginning at the level of the ankle joint and run- ning in a spiral fashion cephal ad and laterally. (See Figure I) If the stress is directed more into abduction, the fracture line may run in a more horizontal plane. Displacement is usually minimal, and treatment is simple. No reduction is necessary. A short leg walk- ing cast for four to six weeks, or a light pres- sure dressing with non-weight bearing on crutches until pain and swelling subside, will invariably yield an excellent result.

It must be recognized, however, that this same external rotation force can cause a var- iety of ankle injuries, depending on the amount of force applied and which structures are damaged. In general, four situations may re- sult, graded 1 through 4 in ascending order of severity.

(1) With slight stress, the external rota- tion force is halted without fracture or significant ligament injury.

(2) With greater force applied, the lateral malleolus may fracture, as described in the opening paragraph, but the stress is not sufficient to cause injury to the medial structures of the ankle. The x-ray shows normal alignment of the ankle mortise.

Figure 1

and there is very little if any tenderness and swelling over the medial aspect of the ankle.

(3) With increased force, the talus may continue further into external rotation and, after fracturing the lateral malleolus, may, through the strong medial deltoid ligament, avulse the medial malleolus. This results in tenderness and swelling over both the medial and lateral aspects of the ankle, and is easily recognized on x-ray as the typical bimalleolar or Potts fracture. This injury requires anatomic reduction, either open or closed.

(4) It is possible that instead of the medial malleolus being avulsedby thepull of the deltoid ligament, the ligament itself may rupture. As in the bimalleolar frac- ture, this results in an unstable ankle, but

PAGE 48

JUNE 1967

ALASKA MEDICINE

is more likely to be missed, because the examination and x-ray findings are usually quite subtle. The important factor here is to distinguish this injury from Type (2), the relatively benign simple fracture of the lateral malleolus, as the treatment and prognosis are entirely different. Two clues are useful in distinguishing the two. First, if the deltoid ligament is ruptured, there will be swelling and tenderness over and distal to the medial malleolus. Second, the ankle mortise will show, or can be made to show lateral displacement of the talus in the ankle mortise, with asymme- try of the mortise. This as5anmetry may be present on the plain A-P film taken with the ankle in 20 degrees of internal rotation. If not it may be demonstrated by an A-P film taken while an abduction- external rotation force is applied to the foot.

Is it necessary to take a stress film in every fracture of the lateral malleolus? No. This view need be taken only if there is in addition to the fracture of the^lateral malleo- lus, tenderness and swelling over the medial aspect of the ankle and in that situation it is a necessity. If instability of the ankle is thus demonstrated, accurate reduction and pro- longed immobilization for a minimum of eight weeks are essential. The following case is used to illustrate such an injury.

The patient is a 28 year old vdiite male who slipped and fell on January 28, twisting his left ankle. He had immediate pain in the ankle and was unable to bear weight on it. The accident occurred in an outlying area, and the patient could not be evacuated until the following day. When seen on January 29, thirty hours after the injury, there was mar-

ked swelling and deformity of the foot. There was swelling and tenderness over the lateral malleolus. In addition, there was marked swelling and tenderness anterior and inferior to the medial malleolus. External rotation stress caused pain over both the medial and lateral malleolar areas. An x-ray was ob- tained (Figure 1). This illustrates the typical fracture of the lateral malleolus, but in addi- tion and most important shows the asyhimetry of the ankle mortise with wideningof the joint space medially. This widening of the joint space medially can occur only if the deltoid ligament has been ruptured. Because of the marked swelling a pressure dressing was applied and the leg was elevated overnight. The following day, under general anesthesia the ankle was reduced by applying an inver- sion adduction force over the lateral malleo- lus and calcaneus. A short leg cast was ap- plied in this position. Post reduction x-rays through plaster revealed satisfactory position and an ankle mortise that was symmetrical medially and laterally. No follow up is avail- able on this patient as he elected to return to his home in California to convalesce.

Occasionally closed reduction of this in- jury will fail. This is invariably due to the torn edges of the deltoid ligament having become interposed between the articular sur- faces of the medial malleolus and the talus. In this instance, open reduction with removal of the deltoid ligament from the joint space is imperative. At this time suture of the liga- ment and internal fixation of the lateral mal- leolus with an intramedullary pin would be advisable.

This injury should be held in plaster a minimum of eight weeks, and preferably ten to twelve weeks.

ALASKA MEDICINE

JUNE 1967

PAGE 49

ALASKA MEDICINE

Through the Retrospectiscope

By Elizabeth A. Tower, M.D.

Former Editor

ALASKA MEDICINE came into being on the crest of the enthusiasm over statehood in 1958 and 1959. In May of 1958 at the last Terri- torial Medical Association meeting in Fair- banks, a committee was appointed to investi- gate the feasibility of publication of an Al- askan medical journal. At the first meeting of the Alaska State Medical Association in June of 1959, the committee report was pre- sented in the form of the Vol. I, No. I (March 1959) issue of ALASKA MEDICINE. In the forward to the first edition, the Editor- In-Chief, Dr. William J. Mills, Jr. , Anchorage orthopedic surgeon, waxed poetic in proclaim- ing “we are given the opportunity now to in- sure that no longer need the unrecorded medical voice be sent plaintively wailing across the waters of the Inland Passage, to quiver in the Susitna Flats, or be sent rum- bling toward the peaks of Mt. McKinley, only to wither and be dissipated in the wilderness. ’ ’ With the enthusiastic acceptance of this committee report, the “Rubicon was crossed” and ALASKA MEDICINE came into being. The second edition carried letters from Herbert Hartley, M.D,, E ditor of Northwest Medicine , with whom Alaska had previously been affil- iated, congratulating ALASKA MEDICINE for having sprung “Like Athena — complete in every detail”; from Joseph Garland, M. D.,

E ditor of the New Engl and Journal of Medicine, who honored ALASKA MEDICINE’S birth in an editorial in his revered journal; from Johnson F. Hammond, M.D., Editor of the JAMA; and even from Bradford Washburn,

PAGE 50

Director of the Boston Museum of Science, informing the editorial staff that his photo- graph used on the cover of the first edition was the North Face of Mt. Brooks, not McKinley as advertised.

In the early years Anchorage internists William O. Maddock, Robert D. Whaley, and Rodman Wilson served as working Editors. Classic articles on such Arctic oddities as botulism in muktuk, salmonella in sea gulls, and climbing Mt. McKinley, were plentiful; eye catching photographs of Alaskan scenes were contributed by physician photographers; and drug companies were eager to finance the journal through their advertising despite the limited circulation which resulted in as many copies of each issue going as exchange jour- nals to other states as to any other category of subscriber. Exchange journals from other states flooded the editor’s office, were pro- jected as the basis for a State Medical Library, and eventually ended up stored in an anti- quated two room log cabin.

In 1961, I took over the management and editing of ALASKA MEDICINE, complete with cabin full of its exchange journals, and con- tinued to bear these dual responsibilities until 1966 when the office of the Alaska Medical Association was established in Anchorage with a full time Executive Secretary. Throughout these five years, ALASKA MEDICINE has always come out, often two months late and frequently undernourished both in scientific content and in advertising, but nevertheless it has come out and has weathered the storms

JUNE 1967

ALASKA MEDICINE

of a bankrupt printing house, a decrease in national advertising by drug companies, an earthquake and tidal wave. (The latter dis- aster was capitalized on with a special Earth- quake Edition, which was published in June 1964, and was in such demand by civil defense agencies through the country that an additional special printing was required.)

Throughout the years the journal has been graced by articles featuring the history of medicine from the days of Steller and Bering (March 1967) through those of the Russian America Company (June and September 1962) and the Dogteam Doctor J. H. Romig (Decem- ber 1963) to the present, and by an informa- tive and amusing gossip column “Muktuk Morsels” compiled until the past year by Dr. Helen Whaley.

Dr. Arndt von Hippel has now taken over

the responsibilities of editorship and already the infusion of new blood is evident in the in- creased scope of the magazine. The business management carried on by Robert Ogden, the Executive Secretary of ASMA, is on a firm foundation. Good days should be ahead for ALASKA MEDICINE, but as before, the mag- azine will only be as good as the quantity and quality of the contributions by the physicians of Alaska. If they do not wish to have “the unrecorded medical voice . . . sent plaintively wailing across the waters of the Inland Pas- sage ... ”, they should commit it to writing and submit it to ALASKA MEDICINE! For my own part, I sincerely thank all of those who submitted articles while I was editor and urge them to so honor Dr. von Hippel. In the meantime, if anyone wishes to have copies of back issues, I still have an attic full of them! !

ALASKA MEDICINE

JUNE 1967

PAGE 51

NEW STATE LEGISLATION OF MEDICAL INTEREST

In the recently completed First Session of the Fifth Alaska legislature several bills of medical interest were passed and signed into law by Governor Walter J. Hickel.

Of particular interest to practicing physi- cians and dentists was the medical “mal- practice” bill (CSSB 142) which the Alaska State Medical Association proposed as a solu- tion to the situation created by the Patrick vs Sedwick decision of 1964 by the Alaska Su- preme Coui^ (ref to March 1967 issue of Alaska Medicine) wherein it appeared that a defendant in a professional liability suit had to prove his innocence. Members of the Alaska State Medical Association with the help of counsel worked with great diligence and persuasiveness for the passage of the bill. Three physician members of the Association appeared at a hearing in Juneau on the bill. It is hoped that the new law will correct the situation and will encourage insurance car- riers to offer liability insurance at reason- able rates in Alaska.

A “Good Samaritan” bill of broad applic- ability also was enacted into law. (SB 89)

Before Alaska law is entirely clear on this matter, however, a section of an exist- ing statute (AS 08.64.365) which in a narrower fashion also applies to emergency care, needs to be repealed. Legislation to do this has been introduced (SB 198) and has been held over for consideration by the Second Session of the Fifth Legislature in 1968.

The overly restrictive statute (AS 18.15.200) concerning the testing of newborn infants for phenylketonuria was repealed and

By Rodman Wilson, M.D.

re-enacted. The new law (CS 73) specifies that the Department of Health and Welfare shall provide tests, test materials, reporting forms and mailing cartons. Time of testing is not specified. A companion bill funding this new service of the Department of Health and Welfare has not yet been passed. Pre- sumably the Department must provide the service within its existing budget.

Senate Bill 53 licensing psychologists was enacted. It creates a board of three psychol- ogist examiners to pass on applicants for li- censure. Psychologists holding a PhD degree in psychology who have had at least one year of experience and who are otherwise accepta- ble to the board are eligible for examination by the board. Licensurebefore January 1968 of psychologists with less than PhD qualifica- tions is permitted for psychologists who have practiced at least one year in Alaska. At the present there are only about 10 psychologists in Alaska who come under the provisions of this act, but standards for licensing new psy- chologists are now set.

An act licensing agencies providing child placement and counselling services (HB 201) was also passed. This bill defines boarding homes, foster homes, institutions, and nurseries and requires their licensing. The act amends an older statute (AS 47. 3 5. 030).

HB270, an act relating to the Alaska Com- prehensive Health Advisory Council was en- acted into law. This law brings certain earlier statutes (AS18.05.051 and .053) into line with federal laws on the same subject and is of importance with respect to future decisions

PAGE 52

JUNE 1967

ALASKA MEDICINE

by the State concerning Title 19 of the Medi- care Act.

HB 329 expands the Alcoholism Advisory Board (AS 44.29.040) from five to nine mem- bers and specifies that one member have special interest and experience in the pro- blems of alcoholism, that one member be a public health nurse, one a social worker, one an alcoholic, one a representative of the liquor industry, and one a member of the public at large.

HB 276, an act relating to premartial blood tests for S5q)hilis, which are required in Alaska, amends existing law (AS 25.05.151) to allow, but not require the laboratories of the State Department of Health and Welfare to charge a fee for the test. If the Depart- ment decides to charge, then, presumably, private laboratories would be in a more favor- able competitive position with respect to these tests.

Several resolutions were made by the Leg- islature. Among them were resolutions cal- ling for the establishment by the U. S. Public Health Service of hospitals at St. Mary’s, Andreafsky, and Unalakleet and for the es- tablishment of a Bethel Premarital Home. HR 6, relating to the boundaries of respon- sibility of private and governmental agencies in the practice of medicine and dentistry, was also adopted. This is a matter which the Alaska State Medical Association may con- sider at the annual meeting in Sitka in June 1967.

Many other bills of medical importance are held over for consideration in the Second Session. Among them are acts relating to air polution (SB 93, SB 163) information to be placed on drivers licenses (SB 10, HB31), professional corporations (SB 80), sale and use of depressant and stimulant drugs (SB 146), standards for eyeglasses and sun- glasses (HB 68), composition of the State Medical Board (HB 132), standards in the an- alysis of blood in prosecution of drunk drivers (HB 178), exemption of school physical ex- aminations on religious groimds (HB 207), revision of the child abuse law to make re- porting of incidents mandatory (HB 300), reg- ulation of clinical laboratories (HB 327), and licensing of physicians (HB 338).

All in all 1967 was a fruitful year with respect to the passage of medical legislation. Alaskan physicians were fortunate to have among the sixty members of the Legislature three practicing physicians. Senator Haggl and of Fairbanks and Representatives Fritz and Beime of Anchorage. These men were in- strumental in the introduction and passage of most of the bills and resolutions described above. The Alaska State Medical Association and component societies also had unaccus- tomed rapport with the other fifty -seven members of the legislature, with the Com- missioner of Health and Welfare, and with the Governor. It is hoped that this climate of cooperation for the good of the health of Al- askans will continue in 1968.

ALASKA MEDICINE

JUNE 1967

PAGE 53

Original Sponsors: Thomas. Smith, Palmer, et al. Offered 3/18/67. Referred; Health, Welfare and Education, In the Senate by the Judiciary Committee. CS for Senate Bill No. 53 in the Legislature of the State of Alaska, Fifth Legislature, First Session.

A BILL

For an Act entitled; “An Act relating to licensure of psychologists; and providing for an effective date.”

BE IT ENACTED BY THE LEGISLATURE OF THE ffTATE OF .ALASKA;

Section 1. AS 08 is amended by adding a new chapter to read:

CHAPTER 86. PSYCHOLOGISTS ARTICLE 1. BOARD OF PSYCHOLOGIST EXAMINERS.

Sec. 08.86.010. CREATION AND MEMBERSHIP OF BOARD. There Is created a Board of Psychologist Examiners. It consists of three li- censed peychologists.

Sec. 08.86.020. APPOINTMENT AND TERM OF OFFICE. Mem- bers of the board are appointed by the governor and confirmed by the legislature for staggered terms of three years. A member serves at the pleasure of the governor.

Sec. 08.86.030. BOARD MEETINGS. The board shall bolda reg- ular annual meeting. The board may hold special meetings at the call of the chairman or of two board members.

Sec, 08.86.040. ASSISTANTS. The board may employ assistants to prepare and grade examinations and to investigate alleged violations of this chapter.

Sec. 08.86.050, TRANSPORTATION AND PER DIEM. Notwith- standing the provisions of AS 39.20, no board member is entitled to transportation or per diem allowances.

ARTICLE 2. ADMINISTRATION OF BOARD AFFAIRS.

Sec. 08.86.070. DUTIES OF THE BOARD. The board shall

(1) pass on qualifications of applicants for licenses;

(2) prepare, administer and grade oral or written examina- tions;

(3) after hearing, suspend or revoke the license of a licensed psychologist who violates a regulation of the board.

Sec. 08.86.080. BOARD REGULATIONS. The board shall adopt regulations to carry out the purposes of this chapter.

Sec. 08.86.090, ADMINISTRATIVE DUTIES OF THE DEPART- MENT. The department shall furnish administrative services for the board.

Sec. 08.86.100. APPLICABILITY OF THE ADMINISTRATIVE PROCEDURE ACT. The Administrative Procedure Act (AS 44,62) ap- plies to regulations and proceedings under this chapter.

ARTICLE 3. LICENSING

Sec. 08.86.120, ENTITLEMENT TO LICENSURE. A person who passes the examination given by the board is entitled to be licensed as a psychologist.

Sec. 08.86.130. QUALIFICATIONS FOR EXAMINATION. A per- son is entitled to take an examination if the board finds he

(1) has not engaged in dishonorable conduct relevant to the practice of psychology:

(2) holds a doctoral degree with primary emphasis on psychol- ogy from an accredited school:

(3) has at least one year's experience acceptable to the board.

Sec. 08.86.140. FEES. Each application fee, renewal fee, annual

and out-of-state license fee is$lS. The fee for a duplicate license is $2.

Sec. 08.86.169. OUT-OF-STATE LICENSE. A person who is li- censed or certified as a psychologist by an authority other than Alaska Is entitled to be licensed in Alaska without examination if

(1) be holds a doctoral degree with primary emphasis on psychology from an accredited scholl; and

(2) the examination and qualification requirements for his out-of-state license or certificate were essentially similar to the exam- ination and qualification requirements for licensure in Alaska at the time he was licensed; or

(3) he Is a diplomate in good standing of the American Board of Examiners in Professional Psychology; and

(4) he completes and returns the proper application forms, and pays the out-of-state certificate fee.

ARTICLE 4. PROHIBITIONS AND PENALTIES

Sec. 08.86.170, USE OF TITLE. Unless he is licensed under this chapter, no person may use the title “psychologist” or any title, designation, or device indicating or tending to indicate that he is a psychologist or practices psychology.

Sec. 08.86.180. PRACTICE OF PSYCHOLOGY, (a) Unless he is licensed under this chapter, no person may practice psychology, offer to practice psychology, or represent to the public that he is a psychol- ogist or that he practices pechology.

(b) This section does not apply to

(1) a person employed by a governmental unit or educational institution vi4io may be required to engage in some phase of work of a psychological nature in the course of his employment:

(2) a student, intern, or resident In psychology pursuing a course of study approved by the board as qualifying training and exper- ience for psychologist, if his activities constitute a part of his super- vised course of study and he is designated by titles such as “psychology intern” or “psychology trainee”;

(3) a qualified member of another profession, such as a social worker, or pastoral counselor, in doing work of a psychological nature consistent with his training and consistent with the code of ethics of his profession;

(4) a person describing himself as a “social psychologist”, if he Is verified to be a social psychologist by the American Sociological Society:

(5) a person practicing medicine, if he is licensed to practice

medicine.

(c) Nothing in this chapter authorizes a person licensed as a psychologist to engage In the practice of medicine, as defined by the laws of the state.

Sec. 08.86.190. NAME UNDER WHICH PERSON PRACTICES.

A licensed psychologist may practice psychology only under his own name.

Sec. 08.86,210. PENALTY. A person whovlolatessec. 170, sec. 180, or sec. 190 of this chapter la guilty of a misdemeanor.

ARTICLE 5. GENERAL PROVISIONS.

Sec. 08.86.230. DEFINITIONS. In this chapter

(1) “psychologist” means a person who practices psychology;

PAGE 54

Introduced 2/23/67. Referred: Health, Welfare and Education. In the House by Fritz by request. House Resolution No. 6, in the Legis- lature of the State of Alaska, Fifth Legislature, First Session, relating to the practice of medicine and dentistry.

BE IT RESOLVED BY THE HOUSE OF REPRESENTATIVES:

WHERES the respective areas properly allocated to private and to government-sponsored practice of medicine and dentistry are ill defined:

WHEREAS this causes unnecessary confusion;

BE IT RESOLVED that the Alaska State Medical Association and the Alaska State Dental Association are requested to clarify the bounda- ries between private and governmental responsibilities in the practice of medicine and of dentistry for the improved health of all Alaska citi- zens: and be it

FURTHER RESOLVED that the Alaska State Medical Association and the Alaska State Dental Association are requested to submit a report of their findings and recommendations within ten days after the conven- ing of the Second Session of the Fifth State Legislature.

Original sponsor: Beime, Offered 3/27/67. Referred: Rules. In the House by the Health, Welfare and Education Committee. CS for House BUI No. 276 in the Legislature of the State of Alaska, Fifth Legis- lature, First Session.

A BILL

For an Act entlUed: “An Act relating to premarital laboratory tests.” BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA;

Section 1. AS 25.05.151 is amended to read:

Sec. 25.05.151. TESTS AND LABORATORIES. For the purpose of this chapter, a standard serological test is a test for syphilis approved by the department, made at a laboratory or clinic approved by the de- partment. The department may make regulations under the Administra- tive Procedure Act (AS 44.62) governing the approval of laboratories or clinics for standard serological tests. The laboratories of the depart- ment (SHALL) make required premarital laboratory tests without charge on the request of any licensed physician or surgeon. In submit- ting the sample to the laboratory the physician shall identify it as a pre- marital test sample.

Introduced 3/7/67, Referred: Health, Welfare and Educationand Finance. In the House by Beime and Fritz. House BUI No. 270 in the Legislature of the State of Alaska. Fifth Legislature, First Session.

A BILL

For an Act entiUed: “An Act relating to the Alaska Comprehensive Health Advisory CouncU,”

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA:

Section 1. AS 18.05.051 is amended to read;

Sec. 18.05.051. COMPREHENSIVE HEALTH IFACtUTiPm an- VISORY COUNCIL, (a) There is created a Comprehensive Health (FA- CILITIES) Advisory Council which shall consist of governmental and nongovernmental members.

(b) The council shall include 11 nongovernmental members, eight (SEVEN) of whom shall be consumers of health services and three (FOUR) of whom shall be representatives of nongovernmental agencies which (.WHO) are concerned with health care services.

(1) Nongovernmental members are appointed by the governor subject to confirmation by a majority of the members of the legislature in joint session. Four members shall serve initial terms of two years, four members initial terms of three years, and three members initial