Archive for the ‘medicine’ Category

What the black college students are rioting about.

Monday, November 16th, 2015


Power line has a post today that seems to me to be right on the topic of what these students want, which is freedom from accountability. They are afraid they are overmatched against white colleagues. They can’t hack it and want a pass. It is called “Mismatch.”

The biggest change since Grutter, though, has nothing to do with Court membership. It is the mounting empirical evidence that race preferences are doing more harm than good?—even for their supposed beneficiaries. If this evidence is correct, we now have fewer African-American physicians, scientists, and engineers than we would have had using race-neutral admissions policies. We have fewer college professors and lawyers, too. Put more bluntly, affirmative action has backfired.

Why is this ? We know that the normal distribution of IQ is a standard deviation lower for blacks than whites.


This is the over all curve with the distribution around an average of 100, by definition.


The curve for blacks has a peak at IQ about 80. White peak at 100 to 104. Asians peak at around 106. What this means is that the average IQ is lower for blacks but this does not mean that all blacks are less intelligent than whites. At an IQ of 110 there is a large difference but the number of blacks who will do well in certain academic fields like Medicine is still significant. It would seem important to identify those blacks who will do well in fields requiring higher than average intelligence but the present system of affirmative action ignores this truth.


The Medical History of the American Civil War. VI

Friday, September 4th, 2015

This will be the final installment of the history. It is in parts because WordPress starts to drop text if the pst gets too long.


Amputations were the most common procedures for war wounds. Below knee amputations had about a 33% mortality. Most deaths were from infection and wound shock, which was a mystery until World War I.


Abdominal wounds were mostly fatal although there were survivors. One of the survivors was Joshua Chamberlain, who was awarded the Medal of Honor for conspicuous bravery at the Battle of Gettysburg.


Chamberlain was a survivor of an abdominal wound and, like many, was left with life-long disability. He had a bladder fistula that continuously drained urine the rest of his life.

Chamberlain offered his services to the governor of Maine who appointed him Lieutenant Colonel of the newly raised 20th Maine regiment. The scholar-turned-soldier would take advantage of his position as second-in-command and studied “every military work I can find” under the close tutelage of his commander, West Point graduate Col. Adelbert Ames.

Though present at Antietam, Chamberlain and his regiment saw their first trial by fire in one of the doomed assaults on Marye’s Heights at Fredericksburg but missed a chance to be involved at the Battle of Chancellorsville due to an outbreak of smallpox. Losses at Chancellorsville elevated Col. Ames to brigade command, leaving Chamberlain to command the regiment in the next major engagement of the war, the Battle of Gettysburg.

On July 2, 1863, Chamberlain was posted on the extreme left of the Federal line at Little Round Top—just in time to face Confederate General John B. Hood’s attack on the Union flank. Exhausted after repulsing repeated assaults, the 20th Maine, out of ammunition, executed a bayonet charge, dislodging their attackers and securing General Meade’s embattled left. Though the exact origin of the charge is still the subject of debate, Congress awarded Chamberlain the Medal of Honor for “conspicuous gallantry.”

He received a bullet wound in the battle of Petersberg that left him with a permanent disability. Even so, he had a successful career. He was wounded six times in all.

After the war, Chamberlain returned to Maine, where he served four terms as the state’s Governor. He later served as president of Bowdoin College alongside former general and Bowdoin alum, Oliver Otis Howard. Prolific and prosaic throughout his life, Chamberlain spent his twilight years writing and speaking about the war. His memoir of the Appomattox Campaign, The Passing of the Armies was published after his death in 1914.

His wound was ultimately fatal.

His old wound became infected in 1914, and on Feb. 24, at age 85, Joshua Chamberlain, the very model of a citizen soldier, died. He was the last Civil War veteran to die of wounds sustained in battle.

He wrote that Army Manual of Leadership, FM -6-22 which is still in use.


Another example of a survivor is Major Henry A. Barnum, a Major of Volunteers who ended the war as a Major General.


The Western Campaign brought forth General William T Sherman, who is in my opinion the greatest American general since Washington, who was really more of a political leader.


Sherman led his army across Georgia after the successful siege of Atlanta which assured Lincoln’s re-election in 1864.


The Siege of Atlanta, which was followed by the burning as depicted in “Gone With The Wind.”


During the siege, instances of Scurvy rose among Sherman’s soldiers and in the residents under siege, Once the siege ended and trains resumed bringing fresh fruit and vegetables, the scurvy declined.


Women played various roles in the war. One captured Confederate officer, while in a prisoner of war camp in Ohio, delivered a child in spite of the fact that she had campaigned and been captured as a male officer. Her husband was also a Confederate officer.


Elizabeth Blackwell was the first American female medical school graduate. She was instrumental in the founding of the US Sanitary Commission, which was modeled on a similar British Commission during the Crimean War. Her organization was called, “the Women’s Central Relief Association of New York,” and had Dorothea Dix as its head.


Dix was a well known health reformer who had previously worked on the treatment of mental illness. She began to recruit female nurses although most nurses during the war were male.


Clara Barton was working in DC when she saw wounded men making their own way into the city after the battle of Bull Run. She organized relief supplies. The Surgeon General, William Hammond, placed her in charge of distributing donated goods to the wounded in 1862.

In 1881, she organized the American Red Cross.


Mother Bickerdyke is a little known but hugely important member of Sherman’s army. She began as a volunteer in Illinois, joined his army and marched all the way to Savannah with the army. They insisted she accompany them in the Grand March in Washington City after the war. She organized field kitchens and bakeries to feed the troops. She organized freed slaves to build her kitchens and field hospitals. It was she who discovered that black berries, growing wild in the South, would prevent scurvy.

After the war ended, Bickerdyke was employed in several domains. She worked at the Home for the Friendless in Chicago, Illinois in 1866. With the aid of Colonel Charles Hammond who was president of the Chicago, Burlington, and Quincy Railroad, she helped fifty veterans’ families move to Salina, Kansas as homesteaders. She ran a hotel there with the aid of General Sherman. Originally known as the Salina Dining Hall, it came to be called the Bickerdyke House. Later, she became an attorney, helping Union veterans with legal issues including obtaining pensions.

Congress had made no provision for pensions or the care of wounded veterans. Mary Ann Bickerdyke worked with Sherman to employ veterans on the railroad that was crossing the plains and to provide care of those wounded and the families of the dead. She and Sherman establish what would eventually became the Veterans Administration. Sherman’s friend and associate General Grenville Dodge was the Chief Engineer for the Union Pacific Railroad.


In May 1866, he resigned from the military and, with the endorsement of Generals Grant and Sherman, became the Union Pacific’s chief engineer and thus a leading figure in the construction of the Transcontinental Railroad.[3]

Dodge’s job was to plan the route and devise solutions to any obstacles encountered. Dodge had been hired by Herbert M. “Hub” Hoxie, a former Lincoln appointee and winner of the contract to build the first 250 miles of the Union Pacific Railroad. Hoxie assigned the contract to investor Thomas C. Durant who was later prosecuted for attempts to manipulate the route to suit his land-holdings.[3] This brought him into vicious conflict with Dodge and Hoxie. Eventually Durant imposed a consulting engineer named Silas Seymour to spy and interfere with Dodge’s decisions.

Seeing that Durant was making a fortune, Dodge bought shares in Durant’s company, Crédit Mobilier, which was the main contractor on the project. He made a substantial profit, but when the scandal of Durant’s dealings emerged, Dodge removed himself to Texas to avoid testifying in the inquiry.

The Medical History of the American Civil War V

Friday, September 4th, 2015

This series is a slightly annotated version of a lecture I have given in several places. One of them was at the Royal Army Medical Corps Museum in the Salisbury Plain.


Two major diseases at the time of the war were Smallpox and Malaria. Both affected large bodies of men in close quarters. Both were infectious but not water borne. Vaccination had been discovered by Edward Jenner in 1796.

In the years following 1770, at least five investigators in England and Germany (Sevel, Jensen, Jesty 1774, Rendell, Plett 1791) successfully tested a cowpox vaccine in humans against smallpox.[20] For example, Dorset farmer Benjamin Jesty[21] successfully vaccinated and presumably induced immunity with cowpox in his wife and two children during a smallpox epidemic in 1774, but it was not until Jenner’s work some 20 years later that the procedure became widely understood. Indeed, Jenner may have been aware of Jesty’s procedures and success.

By the early years of the Napoleonic Wars, Larrey had vaccinated the French Grand Army. By 1870, the French army had forgotten Larry’s work and they were decimated by smallpox while the Prussian army had been vaccinated by Billroth.

Malaria could be treated with Quinine, an extract of Cinchona bark.

Quinine occurs naturally in the bark of the cinchona tree, though it has also been synthesized in the laboratory. The medicinal properties of the cinchona tree were originally discovered by the Quechua, who are indigenous to Peru and Bolivia; later, the Jesuits were the first to bring cinchona to Europe.

The Union Army used 19 tons of cinchona bark to treat malaria in the troops. The Confederates were blockaded and had little to use. The Germans were blockaded in World War I and used their new organic chemistry industry to find alternatives, chiefly from organic dyes, like Methylene Blue.


There obviously was some understanding of the role of mosquitoes in transmission of malaria as we see with the use of mosquito nets in hospitals.


Other infectious disease were scourges although nothing was known about the cause. Tonsillitis was seasonal and diphtheria was treated with tracheostomy although I don’t know how many were done. The story of diphtheria is the story of the great triumph of bacteriology in the late 19th century. In the Civil War the only treatment was tracheostomy.

Wounds were always assumed to be infected and treated accordingly.


The treatment of extremity wounds was almost always amputation as there was no understanding of infection.

Here is an amputation tent with a pile of amputated limbs nearby. Baron Larrey, Napoleon;s surgeon personally amputated 200 limbs in 24 hours at the battle of Borodino. That was one amputation every seven minutes and was prior to the discovery of anesthesia.

There was little treatment available for wounds of the head or the body.


The wounds from a small battle are listed in The History. Head wounds were mostly fatal although a few survived.


Early wound care was mostly in the open as the dressing stations were overwhelmed easily.


Saber wounds, inflicted by mounted cavalry were survivable if the skull was not penetrated and they did not become infected.


The Battle of Chancellorsville was a success for Lee but a great loss resulted as Jackson was lost.


Many believe that all chance of success in the war died with Jackson.


Jackson was shot by his own men as he reconnoitered the battlefield. His left arm was amputated but he did not survive. His wife was with him when he died.


Gunshot wounds of the extremities were most of the survivors. The mortality rate of amputation was 27%. In the Franco-Prussion War, the incompetent French military surgeons had a 50% mortality rate even though antisepsis had been described three years before by Joseph Lister. Lister was treating tuberculosis of the joints, which was a common condition at the time. He found that infection was prevented by carbolic acid.

In August 1865, Lister applied a piece of lint dipped in carbolic acid solution onto the wound of a seven-year-old boy at Glasgow Infirmary, who had sustained a compound fracture after a cart wheel had passed over his leg. After four days, he renewed the pad and discovered that no infection had developed, and after a total of six weeks he was amazed to discover that the boy’s bones had fused back together, without the danger of suppuration. He subsequently published his results in The Lancet[8][9] in a series of 6 articles, running from March through July 1867.

He instructed surgeons under his responsibility to wear clean gloves and wash their hands before and after operations with 5% carbolic acid solutions. Instruments were also washed in the same solution and assistants sprayed the solution in the operating theatre. One of his additional suggestions was to stop using porous natural materials in manufacturing the handles of medical instruments.

The Germans adopted “Listerism” and the French did not. His reports were after the American Civil War although Semmelweis had tried to introduce hand washing in 1846.


Vascular injuries were untreatable and would remain so until Vietnam, when new techniques resulted in salvage of most arterial injuries.

To be continued.

The Medical History of the American Civil War IV

Friday, September 4th, 2015

More of the series on my lecture on the Civil War.


The Ambulance Corps were organized and the photo shows one group during the war.


The next Army Surgeon General was Letterman who changed Tripler’s organization and built larger hospitals and worked on sanitation projects that had been ignored by the early medical services. Disease was a greater risk to soldiers than wounds and had been since Classical Greece. When large numbers often were accumulated without proper sanitation, disease was rampant. Florence Nightingale was one of the first to realize the importance of cleanliness.


One of the greatest medical pioneers of the Civil War was John Shaw Billings who designed hospitals, including The Johns Hopkins Medical Center. He was never Surgeon General but he did organize what became the Public Health Service.


One of Letterman’s new hospitals was this one which was constructed in time for the battle of Gettysburg.


One of the brilliant surgeons who joined up and contributed was this man, John H. Brinton. Typically, he was dismissed by the politicians around Lincoln because McClellan had appointed him.


The most common medical problem was chronic diarrhea.

27,558 Union soldiers died of chronic diarrhea. Without bacteriology, still unknown in 1865, it is impossible to trace the causes.

Typhoid fever killed another 27,056 soldiers.

In the Boer War, in 1899 to 1902, typhoid fever killed thousands of British troops.

of the British Force of 556 653 men who served in the Anglo-Boer War, 57 684 contracted typhoid, 8 225 of whom died, while 7 582 were killed in action.(11) As had been the experience in America, the disease was found to be one which occurred in static camps.

This occurred years after infectious diseases had been identified and the cause of illnesses had been described.

The First Word War was the first war in which more men died of wounds than of disease.


This slide, from the “Medical and Surgical History of the War of the Rebellion, shows the seasonal nature of the disease. The nutritional aspects are seen in the incidence during the siege of Atlanta.


One example of another page of the History. There were over a million cases of acute diarrhea during the war. “Colored Troops” only appeared after 1863.


Diseases were classified according to the medical knowledge of the time. “Miasma” were those which we now know to be infectious. Malaria, for example, mean “Bad Air” in Latin.


Tuberculosis was a severe chronic disease which would not be curable until Streptomycin came along in 1946. There were two forms, “consumption” which was the pulmonary form, was not known to be contagious. “Scrofula” is the cervical lymph node form and is associated with milk from infected cows. This was the form studied by Louis Pasteur who recognized that it was transmissible and that heating milk prevented it.


Treatment of disease was as primitive as one might expect although quinine was known and used by the Union Army. The blockade of the South prevented its use there. Vaccination was widely practiced and opium was used for pain. There was anesthesia since 1846 and chloroform was more common than ether.


Malaria was widespread in the US at the time. Mosquitoes were vaguely known to be associated. Mosquito nets were used although the mechanism was not well understood.

The Medical History of the American Civil War III

Friday, September 4th, 2015

This continues the series from a lecture I have given a few times.


William W Keen was a student when he first served as an Army surgeon at Bull Run. That experience changed the Army medical services and gave a great deal of power to the volunteer organizations.


William Hammond quickly replaced the incompetent surgeons who had been in place when the war began. He was competent but argumentative and clashed with Stanton who became Secretary of War.

Hammond met Jonathan Letterman. Hammond worked with Letterman and Rosecrans on the design of a new ambulance wagon.

The atmosphere in the upper levels of medical services was then one of internal strife and personal conflicts. Hammond—a tall and imposing young man[12]—was no man of intrigue, nor even, according to all accounts, a very flexible person. However, the situation offered him the possibility for advancement. When Finley, the 10th Surgeon General, was fired after an argument with Secretary of War Edwin M. Stanton, Abraham Lincoln, against Stanton’s advice and the normal rules of promotion, named the 34-year-old Hammond to succeed him with the rank of brigadier general. Hammond became Surgeon General of the Army on 25 April 1862, less than a year after rejoining the army.

Lincoln liked “Men who fight” and defended his choices but Hammond was just too hard headed.

On his initiative, Letterman’s ambulance system was thoroughly tested before being extended to the whole Union. Mortality decreased significantly. Efficiency increased, as Hammond promoted people on the basis of competence, not rank or connections, and his initiatives were positive and timely.

On 4 May 1863 Hammond banned the mercury compound calomel from army supplies, as he believed it to be neither safe nor effective (he was later proved correct). He thought it dangerous to make an already debilitated patient vomit. A “Calomel Rebellion” ensued, as many of his colleagues had no alternative treatments and resented the move as an infringement on their liberty of practice. Hammond’s arrogant nature did not help him solve the problem, and his relations with Secretary of War Stanton became strained. On 3 September 1863 he was sent on a protracted “inspection tour” to the South, which effectively removed him from office. Joseph Barnes, a friend of Stanton’s and his personal physician, became acting Surgeon General

Stanton later died of an asthma attack so his “personal physician” was important to him. Calomel was “The Blue Pill” that had been advocated by Benjamin Rush. It was an ancient remedy based on the success of mercury in the treatment of syphilis dating back to Paracelsus in the 14th century. Medicine until the 20th century was quite primitive and many remedies were tried for wildly inappropriate indications.

van gogh

For example, a Van Gogh painting of his doctor shows evidence of digitalis intoxication which might have caused his death. Yellow vision is one indication of overdose of digitalis (sudden death is another) and a Van Gogh painting, Portrait of Dr. Gachet shows the characteristic yellow tint plus an example of the plant held by the doctor.

Anyway, Hammond was replaced after some of his innovations including evacuating the wounded from the Peninsula Campaign of McClellan. They were taken by ship back to large hospitals near DC.



Treatment of the wounded early in the war was primitive and would soon improve under Hammond’s reforms.


The volunteer organizations began to make their influence felt and the Army was unable to resist the reforms.


Tripler, for whom the great Army hospital in Hawaii is named, was chosen by McClellan to be the chief surgeon for the Army of the Potomac. His great innovation was the “Ambulance Corps.”


The “Ambulance Corps” restored the invention of Baron Larrey and began the reforms of the Union

To be continued

The Medical History of the American Civil War II

Friday, September 4th, 2015

This continues the story of medicine in the Civil War. Samuel Gross, a Professor of Surgery at Pennsylvania Hospital in 1860, realized that no textbook of military medicine and surgery existed so he wrote his own in 60 days. It is shown in this exhibit at the Warren Collection at Harvard’s medical library.

manaual of mil surg

The Confederate Army also had no manual so the Gross manual was used by both sides in the war. It was quickly copied for Confederate Military surgeons. A copy of the manual, which was identical to the Union Army manual is preserved at Jefferson Medical College in digital form.


The first battle, famously, was at Fort Sumpter where the commanding office during the battle was actually the medical officer, Samuel Crawford.


The woeful state of the army medical department was recognized immediately and a volunteer organization quickly organized. The first was the US Sanitary Commission. It was rebuffed by the Army but quickly became very powerful. This was a people’s war and the Army was incompetent, as everyone knew.


Here is the cover of Gross’s book. It was used throughout the war, which had enormous influence on American and world Medicine. The book from which this lecture is taken was used by Theodore von Billroth to design the Prussian Army medical corps for the Franco-Prussian War in 1870. The French had forgotten Baron Larrey’s lessons and suffered terribly.


The cover of the Confederate version of Gross’s textbook.


Joseph Woodward was an academic surgeon, such as it was known at the time.

“Woodward was the first scientist to establish photomicrography as a tool for both scientific and medical investigations.” According to an article in the Archives of Pathology and Laboratory Medicine:[2] “In addition to collecting specimens for the museum’s archive, he co-authored the definitive medical history of the Civil War in the 6-volume 1870 publication of the MSHWR.4 Woodward’s technique using aniline dyes for staining thin sections of tissue, along with his pioneering work in photomicroscopy, helped prepare the groundwork for modern surgical pathology.”

The “History” is “The Medical and Surgery History of the War of the Rebellion” of which there are six existing full copies. I found one copy in the USC Medical Library and asked the library staff, who had no idea of its value, to place it in a locked collection room. It would be like finding a copy of “De Revolutionibus” on the shelves of an open university library.


The design of Union Army Hospitals was entrusted to Frederick Olmsted, who had designed New York City’s Central Park. He was, after the war, very involved in establishing The National Park Service.


The first battle of the war illustrated the appalling condition of the medical services of both sides. There were no ambulances and the wounded and to walk back to Washington City, as DC was known then.

A famous American surgeon, who would write one of the world’s great medical textbooks, William W Keen acted as a young army surgeon at the battle.

He studied at Brown University, where he graduated in 1859. He graduated in medicine from Jefferson Medical College in 1862. During the American Civil War, he worked for the U.S. Army as a surgeon. After the war, he spent two years studying in Paris and Berlin.

His “An American Textbook of Surgery” was a hugely influential text and the 1905 edition had a chapter on brain surgery by Harvey Cushing and a chapter on “Appendicitis,” the first use of the term in medical literature, written by John B Murphy, who was the first advocate of early appendectomy for appendicitis.

To be continued.

The Medical History of the American Civil War.

Wednesday, September 2nd, 2015


This is a lecture I have given a few times and am converting to a long blog post. The American Civil War was the first major war since a number of major advances of medicine had occurred. Sanitation had been studied by John Snow and Florence Nightingale. Anesthesia had been discovered by two Americans, Morton and

Unfortunately, antisepsis would not be described until, 1867, after the war. Infection than was the great scourge of the wounded.


The state of medical art before the war was limited.


Baron Larrey was the greatest army surgeon of the Napoleonic Wars. He invented the ambulance and pioneered some sanitary advances but the cause of infection was still obscure.


Benjamin Rush was a famous American physician but little of what he knew or advocated was of use.


The discovery of Ether anesthesia was momentous but it did add the factor that more operations would be attempted before infection was understood.


Semmelweiss was tragic figure who realized that infection was transmissible from physicians’ hands to patients but he was unable to convince his colleagues. His discovery of the uses of hand washing were ignored.


Florence Nightingale discovered the use of hand washing in caring for the wounded but she did not know why it worked. She is a great hero of the British Army and her apartment in Scutari Barracks in Istanbul is preserved in a shrine.


The Scutari Barracks from across the Bosphorus.


I visited the museum about ten years ago and visited her quarters which the Turkish Army preserves.


The history of Military Medicine really begins with Ambrose Pare’ who served several French Kings and who invented the hemostat.


His methods were a huge improvement on the Greeks but not much else can be said for their efficacy.


The American Army in 1860 was tiny and the medical establishment was a joke.


The war resulted in many of the army surgeons resigning to join the Confederacy. The lack of military medical texts resulted in Samuel D Gross, professor of surgery at Jefferson Medical College, writing his own textbook.

To be continued.

Metabolic Syndrome and Obesity.

Monday, July 20th, 2015

I spent an interesting day last Saturday at a USC post-graduate course on “premalignant lesions of the GI react.”

Part of the session discussed the question of obesity and diet. “Fatty liver” is a condition related to obesity and metabolic syndrome.

The Wikipedia definition includes.
1. abdominal (central) obesity,
2. elevated blood pressure,
3. elevated fasting plasma glucose,
4. high serum triglycerides, and
5. low high-density lipoprotein (HDL) levels

Central obesity is not the same as subcutaneous obesity, which is what we all think of. Titters out there is a racial factor with blacks more likely to have subcutaneous obesity without the central obesity involving the liver and internal organs.

Metabolic syndrome and prediabetes appear to be the same disorder, with insulin resistance as a major factor.

Other signs of metabolic syndrome include high blood pressure, decreased fasting serum HDL cholesterol, elevated fasting serum triglyceride level (VLDL triglyceride), impaired fasting glucose, insulin resistance, or prediabetes.

Associated conditions include:
1. hyperuricemia,
2. fatty liver (especially in concurrent obesity) progressing to
3. nonalcoholic fatty liver disease, called NAFL
4. polycystic ovarian syndrome (in women),
5. erectile dysfunction (in men), and
6. acanthosis nigricans.

It is generally accepted that the current food environment contributes to the development of metabolic syndrome: our diet is mismatched with our biochemistry. Weight gain is associated with metabolic syndrome. Rather than total adiposity, the core clinical component of the syndrome is visceral and/or ectopic fat (i.e., fat in organs not designed for fat storage) whereas the principal metabolic abnormality is insulin resistance.


Expensive babies.

Sunday, July 5th, 2015


There is a post on Instapundit today about expensive babies.

It references a new book about a premature baby and is named “Girl in Glass.”

That baby was referred to by the CEO of AOL in a speech to employees explaining why he was cutting benefits for all employees. Her care cost 1 million dollars. The Guardian article goes on to complain about US healthcare (of course) and the cost of premature baby care.

I have a somewhat similar story in my own new book, War Stories. My story is not about a premature baby, although I have one of those too, but a little boy who was born with a heart defect that caused an 18 month hospital stay at Childrens’ Hospital in Los Angeles.

Here it is:

Following my general surgical residency training, I spent an additional year training in pediatric heart surgery at Children’s Hospital. During this time I learned more about the amazing resiliency of children and their recovery from terrible illness. I was also reminded of the constant possibility of catastrophic error in medicine. One young patient named Chris was the best example of the tremendous recuperative powers of children. He was coming in for open-heart surgery to repair a large ventricular septal defect. The ventricles are separated by a muscular wall called the septum, which forms during early fetal development of the heart. The heart has four chambers, two atria and two ventricles, which are separated by walls called “septa,” plural of septum. There are a number of major cardiac anomalies associated with the development of the atrial and ventricular septa and also with the rotation of the heart and the connection of the great arteries to the ventricles from which they arise. Chris was born with a very large defect in the septum between the right and left ventricle. In this situation, the newborn goes into congestive heart failure very shortly after birth. The defect causes no trouble before birth because the lungs are not inflated and the blood flow through the lungs is very small. The cardiac circulation in utero consists of oxygenated blood returning from the placenta through the umbilical veins, passing in a shunt through the liver and then entering the right atrium, which also receives the non-oxygenated venous blood from the body. The oxygenated blood returning from the placenta enters the right atrium and passes through a normal atrial septal opening called “the foramen ovale,” which shunts it directly to the left atrium and left ventricle for circulation out to the body. This bypasses the lungs. The venous blood, and the umbilical vein oxygenated blood that does not go through the foramen ovale, enters the right ventricle where it is pumped into the pulmonary artery. There, because of the high pulmonary resistance it goes through another shunt, the ductus arteriosus, a connection between the pulmonary artery and the aorta, to bypass the lungs and circulate to the body. Minimal flow goes beyond the ductus into the pulmonary arteries until birth. During fetal life, the presence of a ventricular septal defect merely eases the task of shunting the oxygenated blood from the right side of the heart to the left and then out to the general circulation.

When the infant is delivered into the world from its mother’s uterus, it inflates its lungs and very rapidly major circulatory changes occur in the heart and lungs. The pulmonary arteries to the lungs, which during intrauterine life carry almost no blood because of a very high resistance to flow in the collapsed lungs, suddenly become a low resistance circuit with the inflation. The foramen ovale, which has a flap valve as a part of its normal structure, begins to close very quickly and the ductus arteriosus, connecting the pulmonary artery and the aorta, also closes within a matter of several hours. These two shunt closures are accomplished by hormonal changes associated with the changing physiology of the newborn. In very low birth weight preemies, that have low blood oxygen concentration due to immature lungs, the ductus often does not close. In the child with a ventricular septal defect, the sudden drop in resistance to flow in the pulmonary circulation together with the closing of the ductus arteriosus causes the shunt, which was directed from the right to the left heart in utero, to switch to a left to right shunt after birth. The pulmonary circulation is now the low resistance circuit and the systemic circulation; that is, the aorta going out to the arms, legs, and organs is now a relatively high resistance circuit. The flow in the pulmonary circuit goes up tremendously, a short circuit in effect, taxing the ability of the right ventricle to handle the load. At the same time circulation to the organs, the brain and the extremities, drops because of the shunt. This combination of circumstances produces acute congestive heart failure in a newborn. Cardiac output is huge but the flow is going around in a circle through the lungs and then back to the lungs.

Chris had a huge ventricular septal defect and as soon as his lungs inflated and the pulmonary circulation began to assume the normal low resistance of the newborn, he developed an enormous left to right shunt and went into heart failure. The venous return from the body entered his right atrium, passed into the right ventricle and on into the pulmonary artery to circulate through the lungs. Once the oxygenated blood returned to the left atrium on its way to the body, it was shunted back to the lungs because the pressure in the aorta and left ventricle was much higher than that in the right ventricle and pulmonary artery. The short circuit in the heart diverted almost all blood flow to the lungs and little went to the body. The right ventricle, which is thin walled and flat like a wallet, cannot handle the load and quickly fails. The treatment of an infant with a large ventricular septal defect and heart failure is to perform a temporary correction by placing a band around the pulmonary artery above the heart. This accomplishes two purposes. One, it artificially creates a high resistance and equalizes the pressure in the right and left ventricles so that the flow across the ventricular septal defect is minimized. The right ventricular pressure is as high as the left ventricular pressure and little or no shunt occurs. This stops the huge shunt and, with the smaller flow, the ventricle can handle the pressure. It also protects the lungs from high blood flow that damages the pulmonary circulation.

In a related anomaly called “Tetralogy of Fallot” a partial shunt occurs but it is the other way, right to left, since the pulmonary artery is severely narrowed at its origin as part of the anomaly. These children do not go into heart failure, but they are blue because of the mixture of venous blood from the right side and arterial blood from the left. Some patients with ventricular septal defect (VSD) do not go into heart failure because the shunt is not that large but if treatment is delayed and a continued high flow through the lungs persists, in later life they develop irreversible changes in the lungs from the damage to the pulmonary circulation by high flow rates. They become blue later as the increasing pulmonary resistance in the lungs reverses the shunt from left to right to right to left as in Tetrology of Fallot. This condition is called “Eisenmenger’s Complex” and, once it occurs, cannot be corrected. Once this reversal occurs they do not benefit from correction and require heart and lung transplantation. Some VSDs are small and do not produce enough flow to cause trouble, at least in childhood.

Chris had a pulmonary artery banding procedure at about two or three days of life and an extremely stormy course for a very long time postop. He was in the Intensive Care Unit at Children’s Hospital for over a year. He had a tracheostomy for much of that time as he was unable to breathe without a respirator for a year. He had intravenous feeding for well over a year. During this time he had several cardiac arrests and the staff became convinced that he would be brain damaged if he survived. Finally, after 18 months in Children’s Hospital, he went home. This had all occurred before my time. Now, 3 years later, he was being admitted for the definitive repair of his heart defect. The pulmonary band is Teflon tape and does not grow so the pulmonary stenosis, which had saved his life, was now a threat, as it did not permit adequate flow to his growing lungs. He was five years old and was joyously normal. His intellectual development, in spite of everything, was normal and he was a very calm and self-confident little kid. He was not afraid of the hospital or of us, the white coat brigade. Most nurses and staff in children’s hospitals and pediatric clinics avoid white coats preferring colorful smocks to reassure kids that we are all regular folks. The kids are not fooled but it does seem to defuse the tension, especially at first. When we would make rounds on the ward for the few days Chris was in the hospital for pre-op checks, he would go around with us. He wore his little bathrobe and sometimes carried charts for us. He was completely unafraid. I don’t know if it was because he remembered his previous experience; I didn’t think that memory would be very reassuring.

Anyway, the day of surgery came. His mother was a nervous wreck because she had come so close to losing him and here they were risking him again. I did not see much of the family on the day of surgery. His grandfather was a famous movie star, one of the biggest box office leaders of all time, and the hospital had thrown a big luncheon bash for the family as they waited. We heard about it and grumbled that they could have spent the money on a better blood bank (we were having trouble getting blood for elective cases), but no doubt they hoped for a big donation. The surgery, itself, was almost an anticlimax. The data from the original heart cath, when he was a newborn, suggested that he had almost no interventricular septum and we anticipated trouble reconstructing a new septum. As it turned out, his heart, in its growth during the past five years, had developed a good septum with a modest sized defect in the usual place. It was easy to patch and the surgery went well. The other worry with VSDs is the conduction system, the Bundle of His, which carries the electrical stimulation to the ventricles, and runs right along the edge of the defect but this was not a problem. There was no sign of heart block after the sutures were placed and tied. Postop we always took the kids straight to the Heart Room, a combination recovery room and ICU. The nurses there knew more about cardiology than I did and probably more than anyone else at Children’s below the rank of associate professor. His mother came in and stood at his bedside for a while just thankful to have him. I never saw the rest of the family although I did meet his father before he went home. He recovered quickly and completely. I had one more encounter with him about a year later.

After his recovery from the heart surgery he had another operation, this time on his leg. He had been in the hospital for so long as a baby with an IV line in his groin that his hip would not straighten out completely. A few months after the heart surgery he had another operation to release that contracture, the scar that had formed limiting his hip movement. It also went well but had been postponed until his heart was fixed. A couple of months after that procedure he was well enough to climb trees. I know that because he fell out of one of them and cut his forehead requiring several stitches. I removed the stitches in the office a couple of months after I started practice in Burbank. He recovered completely and is now an executive in the entertainment business. I have not seen him since 1972.

I don’t know what Chris’s care cost but I think it was worth it. AOL was foolish to self-insure and not buy reinsurance for catastrophic cases like Chris and Mila’s. There are ways to reform health care and to cut costs but they are not what AOL did or what Obamacare did.

Obamacare Lives !

Thursday, June 25th, 2015

UPDATE: The decision is analyzed at Powerline today with quotes for the decision.

The Affordable Care Act contains more than a few examples of inartful drafting. (To cite just one, the Act creates three separate Section 1563s. See 124 Stat. 270, 911, 912.) Several features of the Act’s passage contributed to that unfortunate reality. Congress wrote key parts of the Act behind closed doors, rather than through “the traditional legislative process.” Cannan, A Legislative History of the Affordable Care Act: How Legislative Procedure Shapes Legislative History, 105 L. Lib. J. 131, 163 (2013). And Congress passed much of the Act using a complicated budgetary procedure known as “reconciliation,” which limited opportunities for debate and amendment, and bypassed the Senate’s normal 60-vote filibuster requirement. Id., at 159–167.

Therefore, Roberts rewrote it. Nice !

Today, the Supreme Court upheld the Obamacare state exchange subsidies.

The Supreme Court has justified the contempt held for the American people by Jonathan Gruber. He was widely quoted as saying that the “stupidity of the American people “ was a feature of the Obamacare debate. This does not bother the left one whit.

Like my counterparts, I have relied heavily on Gruber’s expertise over the years and have come to know him very well. He’s served as an explainer of basic economic concepts, he’s delivered data at my request, and he’s even published articles here at the New Republic. My feelings about Gruber, in other words, are not that of a distant observer. They are, for better or worse, the views of somebody who holds him and his work in high esteem.

The New Republic is fine with him and his concepts.

It’s possible that Gruber offered informal advice along the way, particularly when it came to positions he held strongly—like his well-known and sometimes controversial preference for a strong individual mandate. Paul Starr, the Princeton sociologist and highly regarded policy expert, once called the mandate Gruber’s “baby.” He didn’t mean it charitably.